n 





(lass "R -T .4-^ 
Book » I •& 



CopigM . 



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CDPYRIGKT DEPOSIT. 



PLATE I 




Mottled eruption 
from the arm of 
same ease. 



Severe Case of Scarlet Fever, showing eruption at its height. For 
strawberry tongue of same ease, see Plate XXVIII. (Original.) (Painted 
from a case in the Riverside Hospital.) 



DISEASES 



OF 



INFANCY AND CHILDHOOD 

THEIR 

Dietetic, Hygienic, and Medical Treatment 



A TEXT-BOOK DESIGNED FOR PRACTITIONERS 

AND STUDENTS IN MEDICINE. 



BY 

LOUIS FISCHER, M.D. 

ATTENDING PHYSICIAN TO THE WILLARD PARKER AND RIVERSIDE HOSPITALS OP NEW YORK 
CITY; CHIEF ATTENDING PEDIATRIST TO THE ZION HOSPITAL OF BROOKLYN; ATTEND- 
ING PEDIATRIST TO THE SYDENHAM HOSPITAL; FORMER INSTRUCTOR IN DISEASES 
OF CHILDREN AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND 
HOSPITAL, ETC.; FELLOW OF THE NEW YORK ACADEMY OF MEDICINE. 



EIGHTH EDITION 



WITH THREE HUNDRED AND FIVE ILLUSTRATIONS, SEVERAL IN 
COLORS, AND FORTY-THREE FULL-PAGE HALF- 
TONE AND COLOR PLATES 




PHILADELPHIA 
A. DAVIS COMPANY, Publishers 
English Depot: 
Stanley Phillips, London 

1919 



1?345 



h 



COPYRIGHT, 1907, BY F. 
COPYRIGHT, 1908, BY F. 
COPYRIGHT, 1910, BY F. 
COPYRIGHT, 1911, BY F. 
COPYRIGHT, 1914, BY F. 
COPYRIGHT, 1915, BY F. 
COPYRIGHT, 1917, BY F. 
COPYRIGHT, 1919, BY F. 



A. DAVIS COMPANY 
A. DAVIS COMPANY 
A. DAVIS COMPANY 
A. DAVIS COMPANY 
A. DAVIS COMPANY 
A. DAVIS COMPANY 
A. DAVIS COMPANY 
A. DAVIS COMPANY 



Copyright, Great Britain. All Rights Reserved. 



DEC -6 1919 



Philadelphia, Pa., U. S. A. 

Press of F. A. Davis Company 

1914-16 Cherry Street 



©CI.A5.8G8 8 2 






TO 

HEEMANN M. BIGGS, M.D., 

HEALTTI OFFICER, STATE OF NEW YORK, 

THIS VOLUME IS INSCRIBED 

AS A TRIBUTE TO HIS SCIENTIFIC WORK, 

BY THE AUTHOR. 



PREFACE TO EIGHTH EDITION. 



During the war both clinical and pathological studies in pediatrics 
were at a standstill. The pandemic of influenza, however, afforded an oppor- 
tunity for research in both bacteriology and therapeutics. Advantage has 
been taken of this, and the article on Influenza rewritten, and new charts 
added. 

The general scope of the work, intended for the assistance of the 

general practitioner in both diagnosis and treatment, has been followed in 

this new edition. 

Louis Fiscpier. 

155 West Eighty-fifth Street, 
New York Citv. 



(V) 



CONTENTS. 



PAET I. 

DEVELOPMENT AND HYGIENE OF THE INFANT. 
DIAGNOSTIC SUGGESTIONS. 

CHAPTER PAGE 

I. — Infancy and Childhood 1 

The new-born infant; infancy, childhood. 

II. — The Development of the Various Senses 2 

Keflex actions; sighing; urine; suckling or nursing; supporting the 
head; sitting; playing; stamping with) the feet; the first attempts 
at walking; laughing; kissing; tears; memory; taste; touch; voice 
sounds; very late speaking; sudden loss of speech due to paralysis. 

III. — The Development of the Body 5 

Growth and height; dentition. 

IV. — Diagnostic Suggestions 9 

The pulse-rate; respirations; temperature; eye; gestures; cry; 
tongue; throat; sleep; prognosis; infant mortality; the value of 
X-ray in diagnosis. 

V. — Genekal Hygiene of the. Infant 17 

Hygiene of the mouth and teeth; management of the navel; the um- 
bilical cord; vernix caseosa; bathing the baby; clothing; the nur- 
sery; ventilation; when to take an infant out-of-doors; the nurse- 
maid; method of heating the nursery; light; furniture; bed and 
pillow; proper training of bowels and bladder; hygiene of the nervous 
system; physical exercise. 



PAET II. 

ABNORMALITIES AND DISEASES OF THE NEWLY BORN. 

I. — Peemature Infants 26 

Management of a premature infant; method of feeding; premature 
birth; artificial feeding. 

II. — Prophylaxis and Treatment of the Eyes in the New-born 34 

III. — Diseases and Malformations of the Umbilicus 35 

Granuloma; diphtheritic omphalitis; dangers incident to careless- 
ness in handling the navel; septic omphalitis; Meckel's diverticulum; 
congenital obliteration of the bile ducts. 

IV. — Hemorrhagic Diseases of the Newly Born 39 

Spontaneous haemorrhage; umbilical haemorrhage; heemoglobinuria 
neonatorum; acute fatty degeneration of the new-born; gastro- 
intestinal hsemorrhage. 

(vii) 



viii CONTENTS. 

CHAPTER PAGE 

V. — Injuries of the New-born 43 

Fractures; obstetrical paralysis. 

VI. — Asphyxia Neonatorum 45 

VII. — Fo3tal Ichthyosis 50 

VIII. — Inflammatory and Non-inflammatory Conditions 52 

Icterus neonatorum; sclerema neonatorum; mastitis neonatorum; 
erysipelas in the new-born; tuberculosis in the new-born; peritonitis 
in the new-born; pemphigus neonatorum.. 

IX. — Abnormalities and Congenital Malformations 57 

Angeioma; harelip; cleft palate; tongue-tie; congenital adenoids; 
protrusion of the ears; abnormalities of the air passage; congenital 
stenosis of the larynx; prominent sternum; depressed sternum; 
hematoma of the sterno-mastoid ; cephalhematoma ; caput sueceda- 
neum; congenital cyst of the kidney; congenital sacral tumor; con- 
genital malformations of the rectum. 

PAKT III. 

NUTRITION. 

I. — The Infantile Stomach : Breast-milk and Wet-nursing 65 

Colostrum; breast-milk; the mammary glands; maternal feeding; 
scanty breast-milk requiring mixed feeding; disturbances during breast 
feeding; immunity conferred by breast-milk; additional foods during 
the nursing! period; diet of a nursing mother; wet-nurse; weaning 
and feeding from one year to fifteen months ; management ,of woman's 
nipples; protein indigestion; weight and development. 

II.— Cows' Milk 114 

Certified milk; adulteration; raw milk; chemical examination; fat; 
sugar; protein; mineral salts; starch; alkalies; cream. 

III. — Home Modifications of Milk 150 

Bottle-feeding or hand-feeding; pasteurization; diet for a child from 
one year to fifteen months; diet for a child from eighteen months 
to three years; diet for a child from the third to the tenth year; feed- 
ing of delicate or sick children; substitute feeding; feeding bottles; 
nipples; caloric method of infant-feeding. 

IV. — Percentage Feeding 170 

V. — Other Substitute Foods 173 

Goats' milk; buttermilk feeding; Bulgarian milk; Lahman's vege- 
table milk; Horlick's food; condensed milk. 

VI. — Proprietary Infant Foods 181 

Nestles food; Horlick's malted milk; cereal milk; Wampole's milk 
food; Imperial Granum; Eskay's albuminized food; Mellin's food; 
Mammala; Just's food; Benger's food; peptogenic milk powder. 

VII. — Concentrated Preparations of Albumin 194 

VIII. — Additional Nutrients and Stimulants 198 



CONTENTS. ix 

PAET IY. 

DISEASES OF THE MOUTH, CESOPHAGUS, STOMACH, INTESTINES, 
AND RECTUM, AND DISORDERS ASSOCIATED 

WITH IMPROPER NUTRITION. „ A/VD , 

CHAPTER PAGE 

I. — Diseases of the Mouth : ' 205 

Stomatitis; stomatitis catarrhalis; stomatitis aphthosa; Bednar's 
aphthae; parasitic stomatitis; croupous stomatitis; syphilitic stoma- 
titis; stomatitis gangrenosa; epithelial desquamation; congenital 
hypertrophy of the tongue; bifid tongue; bifid uvula; glossitis; 
ranula; alveolar abscess; angina Ludovici. 

II. — Diseases of the (Esophagus 217 

Acute oesophagitis; croupous or diphtheritic oesophagitis; retro- 
oesophageal abscess; foreign bodies in the oesophagus. 

III. — Diseases of the Stomach 219 

Acute gastric catarrh; pyloric obstruction caused by spasm of the 
pylorus; hypertrophic pyloric stenosis; gastro-duodenitis; chronic 
gastritis; acute dilatation of the stomach; gastroptosis; ulcer of 
the stomach; cyclic vomiting; dyspeptic asthma. 

IV. — Diseases of the Intestines 237 

Infant stools; bacteria of the intestines; diarrhoea; insolation; dys- 
entery; pellagra; intoxication; summer diarrhoea; constipation; 
Hirschsprung's disease; intestinal colic; chronic intestinal indiges- 
tion; appendicitis; pseudo-appendicitis; intussusception; umbilical 
hernia; worms; uncinariasis. 

V. — Diseases of the Rectum 294 

Fissure of the anus; simple catarrhal proctitis; croupous proctitis; 
ulcerative proctitis; haemorrhoids; ischio-rectal abscess; prolapsus 
ani; rectal polypi. 

VI. — Deficiency Diseases and Disorders Arising from the Improper As- 
similation of Nutrition whereby Faulty Metabolism Results. 298 
Faulty metabolism; scurvy; rachitis; decomposition. 

PAET Y. 

DISEASES OF THE HEART, LIVER, SPLEEN, PANCREAS, 
PERITONEUM, AND GENITOURINARY TRACT. 

I. — Introductory 325 

II. — Diseases of the Heart 330 

Reflex symptoms of the heart, tachycardia, bradycardia; pulmonary 
stenosis; persistence of the ductus arteriosus Botalli; endocarditis; 
malignant endocarditis; pericarditis; tuberculosis of the pericar- 
dium; hydropericardium ; myocarditis. 

III. — Diseases of the Liver 346 

Jaundice; acute congestion of the liver; gall-stones; functional dis- 
orders of the liver; displacement of the liver; descended liver; amyloid 
degeneration; fatty liver; cirrhosis; focal necrosis; subphrenic 
abscess. 



X CONTENTS. 

CHAPTER PAGE 

IV. — Diseases of the Spleen and Pancreas 352 

V. — Diseases of the Peritoneum 354 

Acute peritonitis; chronic peritonitis; tuberculous peritonitis: 
ascites. 

VI, — Diseases of the Genital Organs 361 

Hernia; hydrocele; adherent prepuce; phimosis; paraphimosis; hypo- 
spadias; epispadias; cryptorchidism; orchitis; vulvo-vaginitis ; 
simple vaginitis; gonorrhceal vaginitis; vicarious menstruation; 
menstruation prsecox. 

VII. — Diseases of the Kidney and Bladder 370 

Acute nephritis; secondary nephritis; perinephritis; pyelitis; ectopia 
vesicae congenitalis ; indicanuria; acetonuria; diacetonuria; pyuria; 
lordotic albuminuria; haeniaturia; hsemoglobinuria ; glycosuria; 
diabetes insipidus; diabetes mellitus; colicystitis; vesical calculi; 
acute cystitis; chronic cystitis; enuresis. 

PAKT VI. 

DISEASES OF THE RESPIRATORY SYSTEM. 

I. — Diseases of the Nose and Throat 391 

Acute nasal catarrh; naso-pharyngeal catarrh; influenza; foreign 
bodies in. the nose; tonsillitis; follicular tonsillitis; croupous ton- 
sillitis; ulcero-membranous tonsillitis; phlegmonous tonsillitis; chronic 
hypertrophic tonsillitis; tuberculosis of the tonsils; adenoid vegeta- 
tion; pharyngitis; retropharyngeal abscess; spasmodic' laryngitis; 
foreign bodies in the larynx; coughs of reflex origin. 

II. — Diseases of the Bronchi, Lungs, and Pleura 423 

Bronchitis; bronchial asthma; broncho-pneumonia; pleurisy; dry 
pleurisy; pleurisy with effusion; empyema; chronic empyema; tuber- 
cular empyema. 

PAKT VII. 

THE INFECTIOUS DISEASES. 

L— Fever, Bacterial Vaccines 445 

II. — Pertussis (Whooping-cough) 455 

III. — Pneumonia 460 

IV. — Tuberculous Broncho-pneumonia : Pulmonary Gangrene 479 

V. — Acute Tuberculosis 483 

VI. — Diphtheroid. Pseudo-diphtheria. Acute Diphtheria. Chronic 

Diphtheria. Intubation. Tracheotomy 500 

VII.— PvUbella (German Measles). Duke's Disease (Fourth Disease) ... 577 

VIII. — Measles (Morbilli, Rubeola) 584 

IX. — Scarlet Fever ( Scarlatina) 599 

X.— Varicella ( Chicken Pox) 633 



CONTENTS. xi 

CHAPTER PAGE 

XI. — Variola and Vaccination 638 

XII.— Typhoid Fever 646 

XIII.— Erysipelas 658 

XIV.— Malaria '. 662 

XV.— Syphilis : 672 



PAET Yin. 

DISEASES OF THE BLOOD, GLANDS OR LYMPH-NODES, 
AND DUCTLESS GLANDS. 

I. — Introductory 683 

II. — Diseases of the Blood 691 

Anaemia; splenic anaemia; secondary anaemia; pernicious anaemia; 
leukaemia; pseudo-leukaemic anaemia; chlorosis. 

III. — Acute Rheumatism 698 

Muscular rheumatism; torticollis; purpura; purpura rheumatica; 
Henoch's purpura; lithaemia; haemophilia. 

IV. — Diseases of the Glands or Lymph Nodes 711 

Status lymphaticus; acute adenitis; chronic adenitis; tubercular 
adenitis; mumps. 

V. — Diseases of the Ductless Glands 719 

Cretinism; exophthalmic goiter; acute thyroiditis; abnormality of the 
thyroid; diseases of the thymus gland; diseases of the adrenal glands; 
Addison's disease. 



PAET IX. 

DISEASES OF THE NERVOUS SYSTEM. 

I. — Fontanel 733 

Percussion of the skull; the brain; reflexes. 

II. — Convulsions 739 

Headaches; spasmus nutans; speech defects; chorea; hysteria; 
multiple neuritis; pavor nocturnus; masturbation. 

III. — Tetany 756 

Spasmophilia; tetanus; epilepsy; myelitis; spina bifida; hereditary 
ataxy; poliomyelitis; hydrocephalus; meningocele; encephalocele ; 
cyclops; porencephaly. 

IV. — Tubercular Meningitis 779 

Cerebro-spinal meningitis; pachymeningitis; cerebral paralysis; pleu- 
roplegia; pseudohypertrophic paralysis; facial paralysis; cerebral 
abscess; alalia idiopathica; idiocy and imbecility; infantile amaurotic 
family idiocy; concussion of the brain. 



xii CONTENTS. 

PAKT X. 

DISEASES OF THE EAR, EYE, SKIN, AND 
ABNORMAL GROWTHS. 

CHAPTER PAGE 

I. — Diseases of the Ear 812 

Acute catarrhal otitis media; mastoid operation; sinus thrombosis; 
foreign bodies in the ear. 

II. — Diseases of the Eye 819 

Acute catarrhal conjunctivitis; pink eye; pneumococeus ophthalmia; 
purulent ophthalmia; membranous conjunctivitis; granular ophthal- 
mia; blepharitis; hordeolum; phlyctenular conjunctivitis. 

III. — Diseases of the Skin 827 

Eczema; eczema rubrum; eczema intertrigo; urticaria; herpes zoster; 
chloasma; psoriasis; impetigo; pediculosis; miliaria papulosa; 
miliaria rubra; sudamina; lentigo; seborrhcea; furuncle; chronic 
pemphigus; erythema; nsevus; tinea tonsurans; verruca; burns; 
gangrene; scabies. 

IV. — Malignant and Non-malignant Growths 842 

Spindle-cell sarcoma; carcinoma; hypernephroma; lipoma; enchon- 
dromata; angeioma; malignant and non-malignant papillomata; 
granulomata. 

PART XL 

DISEASES OF THE SPINE AND JOINTS. 

Diseases of the Spine and Joints 848 

Pott's disease; flat foot; scoliosis; morbus coxarius; congenital dislo- 
cation of the hip; knee-joint disease; diseases of the ankle-joint and 
tarsus; wrist-joint and elbow- joint disease; acute arthritis. 
Hypodermic medication. 



PAET XII. 

MISCELLANEOUS. 

I.— Dietary 868 

II. — The Examination of the Gastric Contents 875 

III.— Urine 877 

IV. — Bacteriological Memoranda 888 

V.— Anesthetics in Children 890 

VI. — Disinfection 894 

VII. — The Administration of Drugs 895 

VIII. — Local Remedies 896 

IX. — Rectal Medication 898 

X. — Prescriptions for Various Diseases 900 

XL— Table of Doses , 909 



LIST OF ILLUSTRATIONS 



FIGTJKE PAGE 

1. A, Tympanic cavity. B, Otic ganglion. G, Tooth. D, Internal carotid. E, 

Tympanic branch. F, Auriculo-temporal nerve. G, Auricular branch 
of auriculo-temporal nerve. The dotted line connecting B and G repre- 
sents the inferior dental nerve ' 6 

2. Two middle lower incisors. Nine to sixteen months 8 

3. Four upper incisors. Nine to sixteen months 8 

4. Two lateral lower incisors and four molars. Thirteen to seventeen months. 8 

5. Four canines. Sixteen to twenty-one months 8 

6. Twenty milk teeth. Twenty-three to thirty-six months 8 

7. Proper-shaped shoe for infant 21 

8. Incubator 27 

9. Feeder for premature infants 31 

10. Funnel and catheter for forced feeding 31 

11. Weight chart 32 

12. Case of omphalocele 36 

13. Appearance of abdomen four weeks after treatment 36 

14. Diagram illustrating effects of persistence of the omphalomesenteric duct, 

and the formation of the so-called diverticulum tumor 37 

15. Eibemont's tube for inflating the lungs 47 

16. Infant pulmotor 48 

17. A case of angeioma 57 

18. Harelip nipple 58 

19. Congenital cystic kidney 62 

20. Congenital sacral tumor 63 

21. Infant's stomach. Actual size. From a case of malnutrition 69 

22. Infant's stomach. Actual size. Died suddenly from convulsions 69 

23. Infant's stomach. Capacity, 10 ounces. Age of child, eleven months 70 

24. Infant's stomach. Capacity of measurement, 14 ounces 70 

25. Colostrum corpuscles in a drop of milk 75 

26. Heeren's pioscop, for optical milk test 79 

27. Specimen of breast-milk from a young mother, 17 years old 81 

28. Specimen of breast-milk, illustrating very high fat, causing gastric disturb- 

ance 81 

29. Showing a drop of milk under the microscope 90 

30. Drop of breast-milk from a very anaemic woman 90 

31. Holt's milk test set, for testing human milk 91 

32. Nipple-shield for relief of tender nipples 93 

33. 34. Breast-pump 93, 94 

35. Breast-milk taken from a wet-nurse during menstruation 102 

36. Pear-shaped breasts, best adapted for nursing 106 

37. The Chatillon scale 108 

38. Chart showing gain in weight of baby Robert M. F 110 

39. Chart showing gain in weight of baby J. S Ill 

40. Chart showing gain in weight of baby fed on Eskay's food after third week. Ill 

(xiii) 



xiv LIST OF ILLUSTRATIONS. 

FIGUKE PAGE 

41. Chart showing gain in weight of baby A 112 

42. Chart showing gain in weight of baby D. S 112 

43. Centrifugal testing machine, for handpower 133 

44. Graduated cream gauge 134 

45. Marchand's tube 134 

46. Feser's lactoscope 134 

47. Cows' milk, showing fat-globules 135 

48. Chapin cream dipper 147 

49. Author's choice of feeding-bottles 151 

50. Bottle warmer 151 

51. Bottle-brush 152 

52. Anticolic nipple 152 

53. Nipple-sterilizer . 153 

54. Enterprise juice extractor ; 200 

55. Case of sprue (thrush) due to faulty hygiene of the mouth , 207 

56. Case of stomatitis gangrenosa (noma) following scarlet fever 212 

57. Hinged bucket 218 

58. Infantile duodenal bucket with syringe attached, to aspirate bile 225 

59. Drawing from a case of acute dilatation of the stomach 230 

60. Translumination of the stomach with the aid of a gastrodiaphane, in a case 

of gastroptosis. ( Colored. ) 232 

61. a, Normal position of stomach. 6, Position of stomach in a case of gas- 

troptosis 233 

62. Bacterium coli commune 243 

63. Bacterium lactis aerogenes 244 

64. Chart of death-rate from diarrhoea in Manhattan and Bronx, 1898, 1899. . . 247 

65. Chart of death-rate from diarrhoea in Manhattan and Bronx, 1900, 1901 . . . 248 

66. Chart of death-rate from diarrhea in Manhattan and Bronx, 1902, 1903 .... 249 

67. Insolation (heat stroke) 250 

68. Bacillary diphtheria of the colon or diphtheritic colitis. ( Colored. ) 252 

69. Croupous enteritis, diphtheritic colitis 253 

70. A case of acute milk poisoning 257 

71. Exact size of catheter used for irrigating a very young infant 262 

72 to 77. Abnormalities of the sigmoid flexure 267 

78. Rubber bulb syringe 269 

79. Irrigator, with tube attached and hard-rubber points 270 

80. Soft- rubber rectal tube for irrigating the colon , 271 

81. Mechanism of intussusception 286 

82. Umbilical hernia 288 

83. Umbilical hernia truss 289 

84. Case of hydrencephaloid (spurious hydrocephalus) 308 

85. Same child, two years later 308 

86. Rickets, longitudinal section through ossification junction of upper diaphy- 

seal end of femur 309 

87. A case of spurious hydrocephalus, illustrating marked frontal and parietal 

protuberances 310 

88. Rachitic ribs 312 

89 to 92. Illustrating rachitic erosions of the permanent teeth 313 

93. Five- week-old fracture of the humerus in a rachitic child 1% years old .... 314 

94. A severe type of rickets, with enlargement of both condyles of the femur. . . 314 

95. Case of rickets, showing enlarged spleen; also pendulous belly 315 



LIST OF ILLUSTRATIONS. xv 

FIGURE PAGE 

96. Rickets, showing beaded ribs and an enlarged, pendulous belly 317 

97. Rickets, showing beaded ribs 318 

98. Rachitic kyphosis (spine) . Front view . : 319 

99. Rachitic kyphosis (spine) . Back view, same child 319 

100. Decomposition ' 322 

101. Infantile atrophy .' 323 

102. Apex beat in a very young infant 326 

103. Apes beat in a child about 6 years old 326 

104. Apex beat in child about 12 years old 326 

105. Irregular pulse, low tension, from a case of mitral regurgitation 327 

106. Natural size of Bowles stethoscope for examining children 328 

107. Convenient stethoscope for children 328 

108. Case of pulmonary stenosis — congenital — blue baby 333 

109. Child with persistence of the ductus arteriosus Botalli 335 

110. Case of tubercular peritonitis complicated by tubercular empyema 357 

111. Gonococcus. ( Colored. ) 367 

112. Nephritis complicating diphtheria 372 

113. Case of pyelonephritis 377 

114. Exstrophy of the bladder, and prolapse of anus 379 

115. Atomizer 392 

116. Lefferts's posterior and anterior nasal syringe 393 

117. Lenox nasal douche 394 

118. Graduated douche, suitable for older children 394 

119. Influenza bacilli. (Colored.) 396 

120. Influenza — Nephritis — Bronchopneumonia. Recovery 399 

121. Temperature curve in a severe toxic influenza pneumonia ending in recovery. 401 

122. Angina tonsillaris ( Colored. ) . , 403 

123. Vincent's bacillus found in ulcerative angina 406 

124. Throat spray 407 

125. Throat ice-bag . ] 407 

126. The Baginsky tonsillotome 409 

127. The Mackensie tonsillotome 409 

128. Typical adenoid face in a cretin 412 

129. Digital method of exploring the rhino-pharynx for adenoids 413 

130. Temperature chart from a case of retropharyngeal abscess 417 

131. Oil atomizer 418 

132. Steam atomizer 419 

133. Croup kettle . . 421 

134. Diplococcus pneumoniae ( pneumococcus ) . (Colored.) 430 

135. Purulent (suppurative) bronchitis, peribronchitis, and peribronchial bron- 

cho-pneumonia in a child fifteen months old 431 

136. Diphtheria (septic) broncho-pneumonia. Louis B., age three years 432 

137. Diagram for pneumonia jacket opened at side 434 

138. Diagram for pneumonia jacket opened at front 434 

139. Fever curve in a case of dry pleurisy 436 

140. Fever curve in a case of pleurisy, with effusion 438 

141. Diagrammatic illustration of heart and lungs, left-sided pleuritic effusion . . 439 

142. Illustrating a severe localized right-sided empyema 441 

143. James's apparatus for expanding the lungs in empyema 443 

144. Temperature chart, Case II, broncho-pneumonia 453 



xvi LIST OF ILLUSTEATIONS. 

FIGURE PAGE 

145. Focal metastatic hsematogenous streptococcus — pneumonia following angina. 

( Colored.) 461 

146. Croupous pneumonia. (Colored.) 461 

147. Case of influenza and pneumonia 463 

148. Lobar pneumonia of a severe type 467 

149. Case of cerebral pneumonia 468 

150. Cerebral pneumonia, with high temperature and marked decrease in tem- 

perature after cold baths 469 

151. Fever curve during the early period of chronic pulmonary tuberculosis .... 479 

152. Temperature curve during the fifth month 479 

153. Chronic nodular tuberculous broncho-pneumonia 480 

154. Tubercle bacilli and micrococcus tetragenus (sputum). (Colored.) 487 

155. Tuberculosis — horizontal section through lower lobe of right lung of two- 

year-old child 489 

156. Acute pulmonary miliary tuberculosis (cut surface of the lung) 490 

157. Diphtheria or Klebs-Loeffler bacilli; smear preparation from tonsillar de- 

posit. ( Colored. ) 505 

158. True and false diphtheria 506 

159. Section from an iuflamed uvula covered with a stratified fibrinous mem- 

brane, from a case of diphtheritic croup of the pharyngeal organs .... 509 

160. Septic type of diphtheria, complicated by myocarditis 513 

161. Case of nasal diphtheria '. 514 

162. Broncho-pneumonia complicating diphtheria 515 

163. Pneumonia complicating diphtheria 521 

164. Temperature chart from a case of diphtheria complicated by broncho-pneu- 

monia (step-ladder type of fever) 524 

165. Temperature chart from a case of diphtheria complicated by lobar pneu- 

monia 525 

166. Temperature chart from a case of diphtheria complicated by otitis and 

meningitis 526 

167. Temperature chart from a case of diphtheria, showing the specific effect of 

antitoxin on the temperature 535 

168. Method of transfixing and raising the vein 536 

169. Introducer with tube attached 545 

170. Introducer with tube and detached obturator 545 

171. Introducer holding foreign-body tube 545 

172. Extubator . . 546 

173. Built-up tubes for granulation tissue 546 

174. The mummy bandage, showing child in proper position for the dorsal method 

of intubation '. . . . 547 

175 Intubation. Left index finger raising the epiglottis . 548 

176. Tube, passing the epiglottis, entering the larynx 549 

177. Tube, resting on vocal cords, in the larynx 550 

178. Extubation. The left index finger finding the tube 551 

179. Chart showing laryngeal diphtheria complicated by broncho-pneumonia . . . 552 

180. G-avage — method used in forced feeding at Willard Parker Hospital 555 

181. Casselberry method of feeding 556 

182. Temperature chart from a case of diphtheria: croup, intubation 557 

183. Laryngeal diphtheria 564 

184. Diphtheria- — laryngeal stenosis requiring intubation 571 

185. Temperature chart from a case of laryngeal diphtheria 572 



LIST OF ILLUSTRATIONS. xvii 

FIGURE PAGE 

186. Silver trachea cannula used in tracheotomy 575 

187. Hard-rubber trachea cannula 575 

188. Temperature chart, case of rubella . . 580 

189. A case of malignant measles complicated by diphtheria and ending with 

empyema 591 

190. 191. Temperature charts, cases of measles complicated by broncho-pneu- 

monia 592, 593 

192. "Inclusion bodies," case of scarlet fever 601 

193. Septic scarlet fever with myocarditis, suppurative arthritis, double purulent 

otitis, general pyaemia 605 

194. Unusually severe desquamation 607 

195. Chart showing temperature and complications in a case of scarlet fever . . 609 

196. Septic nephritis 615 

197. Drop of urine from a case of post-scarlatinal nephritis 616 

198. Coffey's glass apparatus for hypodermic saline injections 621 

199. Temperature chart, scarlet fever treated with antistreptococcus serum .... 625 

200. Method of nasal syringing employed in the scarlet fever ward of the River- 

side Hospital 626 

201. Pustules surrounded by inflammatory areola 633 

202. Temperature curve in varicella 635 

203. Erysipelas following varicella 636 

204. Fatal smallpox in an unvaccinated infant 638 

205. Temperature curve in variola 640 

206. Smallpox in a child that was vaccinated during the incubation period .... 641 

207. Mild, discrete smallpox in an unvaccinated girl 643 

208. Typhoid infantum in a two-year-old boy 647 

209. Stages in Widal reaction 650 

210. Typhoid fever. Severe haemorrhages 652 

211. Ectogenous streptococcus infection. (Colored.) 658 

212. Fever curve in facial erysipelas 659 

213. Malaria plasmodia, tertian type. (Colored.) 663 

214. Malaria plasmodia, tropical form. (Colored.) 663 

215. Tertian fever (intermittent) 664 

216. Quartan fever ( double tertian ) 665 

217. ^Estivo-autumnal fever (mild type) 666 

218. Spirochseta pallida. Macerated skin of foetus 674 

219. Syphilis. Child 14 years old 677 

220 to 223. Syphilitic teeth : 679 

224. Congenital syphilis before injection of salvarsan 680 

225. Appearance of lesions one week after injection of salvarsan 681 

226. Blood from a case of chlorosis 697 

227. Malignant purpura, complicating nasal diphtheria 706 

228 Case of cervical adenitis in which a positive von Pirquet reaction appeared. 715 

229 to 234. Sporadic cretinism 721, 723 

235 to 242. A case of cretinism 725, 726, 727, 728 

243. Sagittal section of normal head of seven and one-half months' foetus 734 

244. Normal head as seen from above .' 734 

245. Sagittal section of normal head 734 

246. Sagittal section of head immediately after normal, easy labor 734 

247. 248. Sagittal section of head immediately after labor 735 

249. Sagittal section of head of infant six days old 735 



xviii LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

250. Tetany 756 

251. Case of spina bifida 766 

252. Micro-organism causing epidemic poliomyelitis 768 

253. Poliomyelitis 769 

254. Infantile paralysis -. 771 

255. Infantile paralysis 771 

256. Infantile paralysis 773 

257. 258. Case of chronic internal hydrocephalus! 775 

259. Hydrocephalic calvarium (or skull-cap), widely gaping fontanels and 

sutures 777 

260. Case of encephaloeele 778 

261. Tuberculous spinal meningitis 780 

262. Case of tuberculous meningitis, well marked, ending fatally 782 

263. Anatomical illustration, showing the place best adapted for lumbar punc- 

ture 789 

264. Lumbar puncture needle 789 

265. Lumbar puncture made between fourth and fifth lumbar vertebrae 790 

266. Infantile cerebral paralysis 797 

267. Pseudohypertrophic paralysis 801 

268. Facial paralysis following mastoid operation -. . 802 

269 to 271. A case of pseudohypertrophic paralysis 803 

272. Congenital idiocy '. 807 

273 to 276. Imbecile (Louie W.) 808, 809 

277. Complication of scarlet fever seen in my service at Riverside Hospital .... 813 

278. Ear syringe 814 

279. A common type of acute mastoid inflammation following influenza 817 

280. Trachoma, showing round, opaque bodies in upper and lower lids 824 

281. Method of everting eyelid ' 825 

282. Case of gangrene following lobar pneumonia 840 

283. Spindle-cell sarcoma 843 

284. Anterior view of the tumor 844 

285. Enchondromata involving the thumb and index finger 846 

286. Pott's disease 848 

287. Pott's disease, case of Harry F 853 

288. 289. Schoolgirl, showing lateral curvature of spine, due to faulty position. . 855 

290. Side flexion 859 

291. Position maintained while ten or twenty deep breaths are drawn 859 

292.' Sitting-hanging with rod 860 

293. Resistance, especially adapted for young children 860 

294, 295. Tuberculous coxitis 862 

296. Congenital hip dislocation 863 

297. Tubercular elbow- joint 866 

298. Urino-pyknometer, for estimating the specific gravity of small volumes of 

urine 880 

299. The horismascope or albumoscope '. 882 

300. Gas and ether inhaler 890 



LIST OF PLATES. 



PLATE PAGE 

I. — Severe case of scarlet fever, showing eruption at its height . . Frontispiece 

II.— Hess Incubator 28 

III. — The Byrd-Dew method of artificial respiration 46 

IV. — A drop of normal breast-milk from primipara 80 

V. — Microscopic appearance of raw starch-granules 144 

VI. — Microscopic appearance of starch-granules, showing the effect of heat 144 

VII. — Geographical tongue, or epithelial desquamation 214 

VIII. — Intussusception. (Courtesy of Dr. Reu) 286 

IX. — Intussusception. (Courtesy of Dr. Reu) 286 

X. — Cestodes (tape-worms) 288 

XI.— Infantile scurvy 302 

XII. — Femur divided by anteroposterior section in case of infantile scurvy. 302 

XIII. — Subperiosteal haemorrhages in case of infantile scurvy 304 

XIV. — Flaring, cup-shaped, irregular termination of diaphyses in rickets. 

Condition accounts for enlargement of wrists in rickets 308 

XV. — Flaring, cup-shaped, irregular termination of diaphyses in rickets. 

Condition accounts for enlargement of ankles in rickets 308 

XVI. — Chronic enlarged tonsils. Granular pharyngitis 412 

XVII. — Disseminated pulmonary tuberculosis, with collapsed right lung and 

natural pneumothorax 490 

XVIII. — Papulo-necrotic tuberculides 496 

XIX. — Cutaneous reaction with concentrated and diluted tuberculin 498 

XX. — Severe cutaneous reaction. Scrofulous reaction 498 

XXI. — A, Common type of diphtheria. B, Follicular type of diphtheria. C, 

Hemorrhagic type of diphtheria. D, Septic type of diphtheria. 514 

XXII. — Morbilliform antitoxin rash 516 

XXIII.— Schick reaction 520 

XXIV. — Schick reaction 520 

XXV.— Intubation 548 

XXVI.— Extubation 550 

XXVII. — Earliest symptoms of measles 584 

XXVIII. — Forms of tongue in scarlet fever 604 

XXIX. — Furfuraceous, circinate, and flaky desquamations 606 

XXX. — Confluent type of smallpox 644 

XXXI. — Iodophilia. Pus reaction of blood 686 

XXXII. — A, Progressive pernicious ansemia. B, Lienal (splenic) anaemia. O, 

Lienal (splenic) leukemia. D, Acute leukaemia 692 

XXXIII. — Henoch's purpura 708 

XXXIV.— Front view of the foetal skull . . . 736 

XXXV.— Top view of the foetal skull . 736 

XXXVI.— Posterior view of the foetal skull 736 

XXXVII. — Disseminated pulmonary tuberculosis in two-year-old child having 

tubercular meningitis 780 

(xix) 



xx LIST OF PLATES. 

PLATE PAGE 

XXXVIII. — 1, Meningococci in pus cells . 784 

XXXIX. — Cerebrospinal meningitis 786 

XL. — Cerebrospinal meningitis due to the influenza bacillus. 788 

XLL— Intracranial injection in meningitis 792 

XLII. — Normal mucous membrane of the middle ear in the new-born. In- 
flammation of the mucous membrane of the middle ear. Sec- 
tion of the vessel of the mucous membrane containing strepto- 
coccus pyogenes 812 

XLIII. — X-ray of congenital dislocation of hip 858 



PART I. 

THE DEVELOPMENT AND HYGIENE OF THE INFANT. 
DIAGNOSTIC SUGGESTIONS. 



CHAPTER I. 
INFANCY AND CHILDHOOD. 

The New-born Infant. 

There are several anatomical and physiological changes which occur 
when an infant passes from a passive intrauterine to an active extrauterine 
existence. The lungs have had no intrauterine function. They become 
active as soon as the infant makes its first inspiration. The stomach and 
bowels become active the moment the first mouthful of food is swallowed. 
The blood-vessels of the umbilical cord, which have nourished the child 
and connected it with the circulatory system of its mother, rapidly atrophy 
as soon as breathing is established. The following are the most important 
changes that take place during the first month of an infant's life: — 

1. The meconium is expelled. 

2. The umbilical cord separates. 

3. The navel becomes cicatrized. 

4. The epidermis cracks and falls off. 

5. The hair is renewed. 

6. The umbilical vessels are obliterated, and the foramen ovale is closed. 
Infancy. — The term infancy is best applied to that period from the 

end of the first month until all of the milk-teeth have appeared, which is 
about the end of the second year of life. 

There are certain anatomical peculiarities which may be important to 
mention, namely : — 

1. The thymus gland. 

2. The large size of the liver. 

3. The existence of an anterior and posterior fontanel. 

Childhood. — The term childhood is applied to that period from the 
end of the second year to about the sixteenth year. 

Childhood ends when puberty begins. Then follows the" stage of adoles- 
cence. 

a) 



CHAPTER II. 
THE DEVELOPMENT OF THE VARIOUS SENSES. 

Mental Faculties. 1 

The following is the order in which the various senses appear devel- 
oped: taste, sight, touch. 

Reflex Actions. — Yawning may begin at the end of the first week of 
life. 

Sighing 1 commences in the twenty-eighth week. 

Urine is passed and attention called to it by the infant between the 
thirty-sixth and fortieth weeks. From this time on it is advisable to try to 
train the child to be clean and use a chair. 

Suckling or Nursing. — -This seems to be congenitally acquired. Be- 
tween the eighth and tenth months an infant should know enough to prop- 
erly guide a nursing bottle to its mouth. It should also know enough to 
properly inspect its various toys at this age. 

Supporting the Head.- — The infant should support its head for a few 
moments in the fourteenth week, and should be able to properly support 
the head about the sixteenth week. 

Sitting usually commences between the seventeenth and twenty-sixth 
weeks. The child should be able to properly support the body between the 
thirty-sixth and fortieth weeks. About the forty-second week the child 
should be strong enough to support its back thoroughly. Commencing with 
the forty-fifth week the sitting position should be permanently established. 

When children can sit up and play they should be placed on the floor, 
having a clean rug under them. Active movements can be suggested by 
rolling a small ball or giving the child some toy to play with. The tendency 
to put everything into the mouth must be considered. Hence, large toys, 
such as hollow rubber balls, are best. Playing with beans, peas, and bullets 
has frequently given many a physician an opportunity to try his skill in 
removing them from such places as the middle ear, the nostril, and most 
frequently the stomach. 

Stamping with the feet in the forty- fourth week. 

The first attempts at walking appear about the forty-first week. Walk- 
ing unaided is rare before the end of the first year. Two-fifths of all children 



1 The brain, fontanel, and reflexes of the body are described in detail in Part 
IX, "Diseases of the Brain and Nervous System." 

(2) 



VERY LATE SPEAKING. 3 

learn to walk between tiie fourteenth and fifteenth months. Thus children 
must not be expected to walk properly until they are one and a half years 
old. 

Children having suffered with disordered stomach and bowels, whether 
from faulty feeding or inherited disease (syphilis) or other organic dis- 
orders, may, if urged to walk in this weakened condition, invite deformities, 
such as bow-legs. 

Children will not jump, climb, throw things, or turn unaided before 
they are between two and three years old. 

Infants do not learn to imitate before the twenty-eighth week. 

Laughing begins as early as the eighth, sometimes not before the 
seventeenth, week. An infant will laugh heartily with tears in its eyes 
about the forty-fourth week. The mouth will show an expression the mo- 
ment the infant's attention is attracted, between the third and seventh week. 

Kissing with the lips usually at the fifteenth month. 

Tears, when crying, can be noticed after the tenth week. 

Memory. — The memory of an infant can be noticed sometimes before 
the thirtieth week. 

The taste of milk, the sense of feeling, the sight of the mother, the 
presence of the father or the nurse, are distinctly apparent about this same 
time. An infant will notice the absence of its mother about the fourth 
month, and also notice the difference in the sound of the voice. The memory 
seems to be most acute in the fourth year of life. It is surprising to see 
how much children will remember, and how acute their mental faculties 
will be, in the fourth year of life. 

Voice Sounds. — Children will study the movements of the mouth of 
adults, and will learn to note the difference in sound. They will remember 
the meaning of words, especially when brought into use in connection with 
certain objects or places. Words will be uttered in accordance with no dis- 
tinct rule. This is a peculiar individuality which is difficult to record. 
One child will speak ten words at the age of ten months, and be in a 
normal condition. Another child will speak but six words at the age of 
sixteen months and yet be physically and mentally in a normal condition. 
This shows the marked difference in various children in apparently good 
health. 

Vert Late Speaking, Slow Development, Good Prognosis. 1 

The center of speech may be inactive, and show no signs of develop- 
ment until the end of the second year. If the child is otherwise healthy 
no alarm need be felt at this state of affairs. If, however, the child is 
backward in its physical development as well as its mental development, 



See article on "Alalia Idiopathica," Part IX. 



4 



DEVELOPMENT OF THE VARIOUS SENSES. 



then treatment must be sought to remedy this condition. If a child has 
rickets, its soft bones and flabby muscles require restorative treatment. 

Sudden Loss of Speech Due to Paralysis. 

If an infant shows proper development, commences to speak, and for 
no apparent reason stops speaking, the cause of the condition should be 
carefully investigated. For example: A child suffering from a severe 
infectious disease, like diphtheria, may, during convalescence, develop 
paralysis, which might cause the sudden cessation of speech. The neglect 
of treatment at such a time may result in permanent injury to the child. 



CHAPTER III. 
THE DEVELOPMENT OF THE BODY. 

Growth and Height. 

The average height of the new-horn male is from 19y 2 to 20 inches 
(ahout 50 centimeters). In the female from lD 1 /^ to 19% inches (about 
48.5 centimeters). Holt's average is one inch more in both male and 
female children at birth. A child grows most rapidly during its first year. 

Table No. 1. 
Increase during 

First year 5 to 6V2 inches. 

Second year 2V 2 to 3 1 /. inches. 

Third year 27 s to 2-/ 3 inches. 

Fourth year ahout 2 inches. 

Fifth to sixteenth year annual increase from 1 V 2 to 2 inches. 

Sixteenth to seventeenth year . 1 1 / 2 inches. 
Seventeenth to twentieth year . 1 inch yearly. 

Diseases of the bones, rickets, and scrofula retard growth. A child 
should begin to walk at the end of twelve months. If a child, when com- 
mencing to walk, uses chiefly its toes and has a limping gait, more espe- 
cially if symptoms of pain be noticed in one knee, and tenderness be caused 
by handling the limb, commencing hip-joint disease may be inferred. 

Dentition. 

Dentition is regarded by most authors as a physiological process. Teeth 
are developed at birth and grow with the infant until they pierce the gum. 
A series of nervous disorders occur after the fourth month and during the 
eruption of the teeth. Such symptoms are a very warm mouth, red and 
inflamed gums, and an excessive secretion of saliva. Eachitic children and 
those having a highly sensitive nervous system will be very restless at night. 
They will roll the head and frequently cry with pain. A finger will usually 
be found between the gums, and the child will try to bite everything within 
its grasp. These symptoms seem to disappear after the eruption of the 
tooth, so there seems to be some relation between the tooth and the symptoms 
described. Botch states that in certain infants, during the completion of 
the development of a tooth, symptoms connected with the ear will manifest 
themselves. The symptoms are usually produced by a congestion of the 
blood-vessels of the ear which is accompanied by pain and sometimes results 
in an inflammation. 

(5) 



6 



THE DEVELOPMENT OF THE BODY. 



Treatment of Inflamed Gums. — When the gums are tense and inflamed, 
severe nervous manifestations frequently exist. An incision made into the 
gums, deep enough to reach the tooth, has frequently been the means of 
producing relief by local depletion. Eelieving the tense gum besides 
abstracting the blood has served me in some cases. The indiscriminate 
lancing of the gums must be warned against. In most cases local applica- 
tion will relieve. The application of a 1 to 5000 solution of adrenalin acts 
very well. It may be repeated every hour. A drop of laudanum on absorb- 
ent cotton placed in the middle ear seems to act well in some instances. 
In rare instances we will be told that a child has had convulsions. I must 
emphatically reiterate that such cerebral or nervous symptoms are apt to 
occur in the sick infant, and will never occur in the healthy infant. 




Fig. 1. — A, tympanic cavity; B, otic ganglion; C, tooth; D, internal 
carotid; E, tympanic branch; F, auriculo-temporal nerve; G, auricular 
branch of auriculo-temporal nerve. The dotted line connecting B and C 
represents the inferior dental nerve. (Rotch. ) 



The association of bronchitis or diarrhoea must be looked upon as 
entirely independent of dentition. The laity are very willing to ascribe 
most disorders arising at or about the period of dentition as clue to the 
teething. The following case will illustrate how careful one must be not 
to be guided by the statements of irresponsible persons, and diagnose den- 
tition : — 

A child, fifteen months old, was seen by me in consultation. This was a well- 
nourished, breast-fed infant, and had four incisors, two upper and two lower. The 
mother stated that the child had had a cough and fever at and before the appearance 
of each tooth. She was very emphatic in stating that her baby was "teething." 
There were anorexia and slight constipation. A dose of castor-oil was given, but the 
symptoms continued. The child was very thirsty and seemed to lose flesh. The 
temperature in the rectum was 103° F., pulse 150, respiration 30. An examination 
of the chest showed moist rales and quite diffuse rhonchi. There were a marked area 
of dullness and bronchial breathing in the upper lobe of the right side. The diag- 
nosis of pneumonia was made. Four or five weeks later I again saw this child. The 



DENTITION. 7 

cough still existed, and a suspicion of whooping-cough was expressed. An explora- 
tory puncture showed pus. The diagnosis of empyema was made. The child was 
operated upon and made a brilliant recovery. 

The teeth usually appear, according to Professor Baginsky, between 
the third and tenth months. The usual rule is for normal dentition to begin 
about the seventh or the eighth month. 

In a great variety of children premature teething is recorded; I have 
seen a great many children born with two or more teeth. 

Eachitic children, as a rule, teeth very early or very late. In the. large 
children's sendee with which I have been connected I have -observed the 
eruption of teeth many times as early as two or three months in very rickety, 
bottle-fed children. These teeth soon decay, and are then known as carious 
teeth. 

In syphilitic (congenital) children premature dentition is frequently 
seen. 

The first teeth are known as milk-teeth. 

The following table will show the usual rule followed by normal denti- 
tion in the average child : — 

Table No. 2. 

19 | 11 | 13 | 5 | 3[ 4 | 6 | 14 1 9 | 17 

20 | 12 [ 15 | 7 | 1 | 2 | 8 | 16 | 10 | 18 

The milk-teeth are twenty in number ; thus, one and two are the lower 
incisors, usually first teeth ; then follow three and four, upper incisors. 

Normal children usually teeth in pairs, and not singly, whereas rachitic 
children usually have an eruption of single teeth, and distinct backward- 
ness in their appearance. Deciduous teeth, commonly called milk-teeth, 
remain until a child is 6 years old, when the permanent teeth appear. 

Baginsky emphasizes the fact that enough stress is not laid on the 
clinical importance of carious teeth as indicating tuberculosis and scrofulous 
conditions. In the section on treatment of rickets I have mentioned the 
value of a nitrogenous diet, especially proteins (albuminoids), to aid in 
the formation of bony structures. The teeth are also included in this 
category. 

Thus, when such drugs as glycerophosphate of lime or iron and hygienic 
measures are indicated for the treatment of rickets they are of especial 
value when backwardness in teething exists. 

When diarrhoea or cholera infantum cleanses the system and when the 
disease is arrested or well under way, normal physiological conditions, such 
as dentition previously delayed, are vigorously continued. Frequently teeth 
will appear immediately following such an acute disease ; thus, an apparent 
delayed dentition, due to a pathological process, will be attributed by the 
laity to the disease or sickness called teething. 



THE DEVELOPMENT OF THE BODY. 




Fig. 2. — Two Middle Lower In- 
cisors. Three to Ten Months; 
Average, Seven Months. 




Fii 



3. — Four Upper Incisors. Nine 
to Sixteen Months. 




Fig. 4. — Two Lateral Lower Incisors and Four Anterior Molars. 
Thirteen to Seventeen Months. 





Fig. 5. — Four Canines. Sixteen to 
Twenty-one Months. 



Fig. 6.— Twenty Milk Teeth. Twenty- 
three to Thirty-six Months, although the 
Average is Twenty-four to Thirty Months. 



CHAPTER IV. 
DIAGNOSTIC SUGGESTIONS. 1 

It is a very difficult matter to give as distinct clinical pictures of 
children in certain diseases as we can of adults. The following points are 
important enough to be noted : — 

First. — There is an absence of expectoration in respiratory diseases. 
Infants cough and usually swallow their expectoration. 

Second. — An absence of distinct ■ chills and rigors as seen in .adults. 

Third. — The tongue, so valuable in adults as an aid to diagnosis, may 
frequently be overlooked as a symptom of importance in young children. 

Fourth. — Very high temperature and pulse-rate may be associated with 
trivial, just as well as they only too frequently denote serious, conditions. 
A normal temperature is frequently seen in septic diphtheria; we must, 
therefore, not judge a case by the temperature alone. 

Fifth. — The great peristaltic activity and the anatomical difference 
in the shape of the stomach at birth render such symptoms as vomiting and 
diarrhoea trivial compared with what such symptoms would denote in an 
older and fully developed child. 

Dr. "West ably says: "You cannot question your patient, or, if old 
enough to speak, still, through fear, or from comprehending you But im- 
perfectly, he will probably give you an incorrect reply. You try to gather 
information from the expression of his countenance, but the child is fretful 
and will not bear to be looked at ; you endeavor to feel his pulse, and he 
struggles in alarm; you try to auscultate his chest, and he breaks into a 
violent fit of crying." Such technical difficulties each medical man must try 
to overcome, and here it is that the ingenuity of the practicing physician is 
brought into play. 

There are a great many important points which have a bearing upon 
the diagnosis and which it is well to formulate : First, try to examine the 
infant when asleep. Xote the color of the face, if flushed or pale; the 
color of the lips, if white or cyanotic ; the condition of the skin, if dry or 
moist; if perspiration is confined to the head or forehead, or if it affects 
the whole body. Second, note the frequency and character of respiration, 
if painful or natural; moaning, twitching, or grinding of teeth; the action 



1 The Babinski reflex, Kernig's sign, tache cerebrale, and the technique of lumbar 
puncture are described in detail in the chapter on '•Meningitis." Part IX. 

(9) ■ 



10 DIAGNOSTIC SUGGESTIONS. 

of the nostrils, if quiet or dilating; the eyes if closed, partly closed, or 
staring. Third, note the condition of the fontanels, if closed or open, if 
pulsating, if distended, full, and bulging, or if sunken. 

The pulse-rate should be noted. In counting the pulse-rate certain 
allowances must be made for excitement. The sudden slamming of a door, 
etc., will startle infants and cause the pulse to increase at times from ten 
to twenty beats. 

The pulse varies in infants from 110 to 150. It may be irregular, con- 
sistently with health. After the seventh year it is found to be quicker in 
the female. It is sometimes slower during sleep. A very slow pulse is not 
always an indication of cerebral disease. 

In a study of over 1000 children in health, the following average table 
of pulse was found (Fischer) : — 

Table No. 3. 

At birth , 130 to 140 

First year 115 to 130 

Second year 100 to 115 

Third year - . . 90 to 100 

Seventh year 86 to 96 

Fourteenth year . . 84 to 94 

Table No. 4. 

Pulse Rate: 

While Asleep. Aivake, Crying. 

Infant ten days old 146 164 

One month old 150 176 

Two months old 120 150 

Three months old .112 148 

Six months old 98 122 

One year old 100 120 

Two years old . 98 108 

A diagnosis can frequently be made by the condition of the pulse-rate 
added to the general condition. If an infant is suddenly taken ill with 
fever, with symptoms of nausea and vomiting, a dry coated tongue, and the 
pulse-rate about 130, we may look for an acute gastric fever. Such is 
usually the case if the history points to a diet of cake and pie, or cheese, in 
a very young child. 

If, however, the child is feverish and vomits and the pulse-rate is 
between 70 and 80, then we should suspect tubercular meningitis rather 
than an acute febrile disease. Note the condition of the child's awakening ; 
every young infant in a healthy condition awakens with a smile, does not 
frown, is not peevish. 

Frequently, if the clinical history is looked into, we can learn just 
when the infant first became restless or showed some sign of disturbance. 



TEMPERATURE. 11 

This will usually mark the beginning of an illness, if the same is an acute 
condition. 

■ The Respirations. — From 1 to 2 years of age a child should breathe 
from 24 to 36 times in a minute. The breathing should be diaphragmatic 
in character; in ordinary breathing there should be no recession of the 
chest walls; this occurs in sobbing or if a mechanical impediment exists 
to the entrance of air into the lungs. 

The number of respirations per minute ranges from 30 to 50; in 
early infancy 39 is the actual average. 

Table No. 5. 

From two months to two years, the average is 35. 
From two years to six years, the average is 18 during sleep, 23 awake. 
From six years to twelve years, the average is 18 during sleep, 23 awake. 
From twelve years to fifteen years, the average is 18 during sleep, 20 awake. 

Temperature. — The normal temperature of the child, taken in the 
rectum, varies between 99%° and 100° F. Fever undoubtedly exists if tem- 
perature over 100° F. is noted. The cause should be searched for. No 
indication is more simple or more valuable than that supplied by the ther- 
mometer. By its aid alone we are often led to suspect the advent of typhoid 
or scarlet fever, or to detect some latent pneumonia, or tubercle produc- 
ing irritation, or some other malady which we had overlooked. It should 
be remembered that rigors do not occur in very young children, but that 
convulsions and delirium correspond in a great measure to rigors and 
headache in an adult. The temperature is an important guide as to the 
condition of an infant. The pulse-rate and the character of the pulse are 
even more important. 

Dr. Finlayson has bestowed much attention on the subject of tempera- 
ture in young children, and his observations go to show : — 

1. That there is a fall of temperature normally in the evening of 1°, 
2°, or even 3° F. 

2. This fall may take place before sleep begins. 

3. It is usually greatest between 7 and 9 p.m. 

4. The minimum is at or before 2 a.m. 

5. After 2 a.m. it again rises, and that independently of food, etc., 
being taken — rises, in fact, during sleep. 

G. The fluctuations between breakfast and tea are usually trifling. 

7. The rise in a day to 104° or 105° F. precludes typhus and typhoid, 
not scarlatina. 

8. In typhoid a gradual increase for the first four days with morning 
remissions is diagnostic (Wunderlich). 

9. In tubercle the evening temperature is as high or, according to Dr. 
Ringer, higher than in the morning. 



12 DIAGNOSTIC SUGGESTIONS. 



Eules to be Observed in Taking Temperature of Infants. 

1. Be sure you have a good thermometer. 

2. Inspect it and see that it is well shaken down to below normal before 
using it. 

• 3. Anoint it with vaseline or oil. 

4. Always use the rectum for infants. 

5. Eemember that infants always object to interference; hence the 
thermometer should be watched; otherwise an accident may happen. 

6. The best position for the child is to lay it face downward on the 
nurse's lap. 

7. Eemember that impacted faeces in the rectum and fermentative con- 
ditions usually increase the temperature. 

The Eye. — Squinting in acute illness is a grave prognostic; it may 
occur from reflex irritation, or from paralysis, or from convulsions, but the 
convulsions may cease and the squint remain for awhile or even' perma- 
nently. When strabismus occurs in tubercular meningitis, it is usually a 
fatal sign. 

A small pupil is not so common as a large one; it occurs in active 
congestion, in opium poisoning, and in sleep. It should be remembered 
that the eye is always more or less turned up beneath the upper lid. Large 
pupils, if equal in size, are only of grave import when insensible to light; 
inequality of the pupils coming on in acute illness is a very grave prog- 
nostic. M. Jadelot has noticed that the form of the pupil is irregular in 
children suffering from the intestinal irritation of worms. 

The following aphorisms of Bouchut are of practical value : — ■ 

1. In early childhood there is no relation between the intensity of the 
symptoms and the material lesion. The most intense fever, with restless- 
ness, cries, and spasmodic movements, may disappear in twenty-four hours 
without leaving any trace. 

2. Abundant perspiration is not observed in very young children; it 
is entirely replaced by moisture. 

3. Fever always presents considerable remissions in the acute diseases 
of young children. 

4. In the chronic diseases of infancy, fever is almost always inter- 
mittent. 

5. When children are asleep their pulse diminishes from 15 to 20 
beats. The muscular movements which accompany cough, crying, agitation, 
etc., raise the pulse 15, 30, or even 40 pulsations. 

6. The diseases of youth always retard the process of growth. 

It is a good plan to auscultate the chest before resorting to percussion. 
The back of the chest is the most important to auscultate in a sick child. 
If there are no physical signs pointing to bronchitis or pneumonia in the 



THE CRY. 13 

back of the lungs, then it is unlikely that the front of the chest will show 
any signs. To be sure, however, both back and front of chest should be 
examined. 

Dr. Vogel gives a valuable caution, viz., that dullness on the right side 
posteriorly is a normal physiological condition. Owing to abdominal 
pressure the abdominal organs, and notably the liver (as especially affecting 
the right side), is pressed upward. 

Gestures are often significant. In brain disease the child puts its 
hand to its head, pulls at its hair, rolls its head on the pillow, and beats the 
air. In abdominal disease the legs are drawn up, the face is sunken and 
anxious, and the child picks at the clothes. In urgent dyspnoea it tears 
at its throat or puts its hand in its mouth, especially when false membranes 
are forming, or the tongue is much furred, as in fever, etc. 

The cry varies ; it is labored, as if half suffocated, or as if a door were 
shut between the child and the hearer, in pneumonia and capillary bron- 
chitis ; it is hoarse in croup, brassy and metallic, with crowing inspirations ; 
in cerebral disease, especially in hydrocephalus, it is sharp, shrill, and soli- 
tary, the so-called "cri hydrocephalique," whereas in marasmus and tuber- 
cular peritonitis it is moaning and wailing. Obstinate and long-continued 
crying lasting for hours is referable usually to one of two causes; earache 
or hunger. A louder, shriller cry, also on coughing or produced in moving 
the child, is pleuritic. A cry accompanied with wriggling and writhing and 
preceding defecation is intestinal. M. Billard distinguishes between the 
cry and the return, the cry proper being the expiratory act, while the 
return occurs during inspiration. The cry proper is sonorous and prolonged ; 
the return is shorter and sharper; the return is feeble in young infants, 
but increases in strength as the child grows older. It is the return that 
grows weak or ceases toward the end of all diseases. Moaning is especially 
characteristic of the alimentary canal. 

The Tongue. — The following are the chief indications derived from 
observations of the tongue : 1. A furred tongue with whitish fur scattered 
over it indicates dyspepsia and intestinal irritation. 2. A red, dry, hot 
tongue points to inflammation of the mouth, stomach, etc. 3. Aphthae often 
result from sheer starvation and neglect. 4. A pale flabby tongue marked 
at the edges with the teeth shows great debility. 5. White fur is generally 
indicative of fever. 6. Yellow fur of liver and stomach derangement of 
long standing. 7. Brown fur of a low typhoid condition. Besides these, 
special conditions, as the "strawberry tongue" of scarlatina, the glazed 
tongue of dyspepsia, etc., will be noted under the special diseases they char- 
acterize. 

The Throat. — No matter what the child suffers with, it is imperative 

' to examine the throat. Advantage can be taken of the infant while crying 

to observe the tongue, the teeth, the gums, the mouth in general, and the 



14 DIAGNOSTIC SUGGESTIONS. 

throat in particular. The neglect of an examination of the throat has fre- 
quently been the means of disseminating diphtheria. Many a child's life 
has been sacrificed by failure to make a minute examination of the throat. 

Sleep. — Healthy infants normally sleep from eighteen to twenty hours 
out of twenty-four. Thus, if infants are restless and do not sleep, such 
insomnia denotes illness. 

Presuming that we have had an opportunity to examine the infant dur- 
ing sleep, let us then have the child undressed and notice the surface of the 
skin ; it should be mottled, the flesh firm, the skin smooth and elastic to the 
touch, and not flabby ; there should be no impediment to the motion of either 
the arms or legs, they should move freely; the joints should be noted if they 
are swollen, if large or small ; the epiphyses of the long bones should be care- 
fully noted, and evidences of rickets determined, as this has an important 
bearing on various infantile diseases. 

I have previously called attention to the necessity of undressing a child 
for its proper examination. Fever which cannot be explained may have- an 
eruption of scarlet fever on the body. This can only be detected by undress- 
ing and examining the infant. 

Prognosis. 

In giving an opinion as to the probable outcome of a given case, we 
must be guided by the following conditions: Has the infant a good founda- 
tion— heen breast-fed in infancy — or are we dealing with a marasmic or 
rachitic infant? The resistance offered to the acute infectious diseases by 
an infant nursed at the breast is most probably due to the antitoxic virtues 
found in the milk. The temperature should not always be the guide. 
Infants respond very quickly to disease and show very high temperatures. 
They are more susceptible to infections than adults. A high fever may 
appear and disappear very suddenly; hence we should not base our prog- 
nosis on the sudden appearance of temperature. The pulse — the heart 
action — is our best guide in estimating the outcome of a given case. The 
amount of food taken during an illness and the digestion and assimilation 
of the same are important factors in estimating the condition of the little 
patient. Constant fever, loss of appetite and sleep, with resulting heart 
weakness, should be regarded as symptoms of a critical condition. 

Infant Mortality. 

Through the vigilance of the health department New York City has 
secured a good milk supply. The feeding of impure milk was always con- 
sidered the reason for the high infant mortality, especially during the 
summer months. Although the mortality has been reduced to 22 per cent., 
there is still room for improvement. The infant mortality in infectious* 



X-RAY IN DIAGNOSIS. 



15 



diseases has also been greatly reduced. This is largely due to the immuniz- 
ing injections of antitoxin and the more generalized use of antitoxin as a 
preventive measure. 

The statistics of the mortality in diphtheria, scarlet fever, and measles 
show a reduction in the mortality- of 10 to 20 per cent, during the last 
twenty years. The sanitary environment has changed. The beneficial 
change has been largely due to three factors : first, the better milk supply ; 
second, preventive measures, such as immunizing doses of antitoxin to pre- 
vent diphtheria after exposure, and, third, to fresh air — this implies windows 
open, new parks, roof gardens, and education of the masses to a proper 
understanding of the virtues of fresh air in health, and especially in disease. 

The publie is learning to appreciate the benefits of open-air classes for 
the anaemic children in the public schools. Eoof-garden instruction and the 
strict supervision of the public schools, due to the efficiency of medical 
inspectors, have lessened contagion among school children. The parents 
of children suffering with adenoids and diseased tonsils are notified and 
advised regarding their danger. The open-air treatment of tuberculous 
joints established by the S. I. C. P. and the sun therapy (heliotherapy) 
have accomplished excellent results at Coney Island and elsewhere. Such 
therapeutic measures prolong life and reduce mortality. 



Table No. §.—Two Hundred Deaths — Their Mode of Feeding (Louis Fischer). In- 
quiry into 200 Deaths, Taken at Random at the Children's Service of the German 
Poliklinik and West Side German Dispensary. 



Age in Months. 


Cases 
Investigated. 


On Breast 
Only. 


On Breast 
Partially. 


Bottle Feeding 
Only. 


0- 3 


78 
30 
64 
28 

200 


5 

7 

12 

9 

33 


8 
12 
16 
12 

48 


65 


3- 6 


11 
36 

7 

119 


6-9 


9-12 





The above children were inhabitants of both the East and West Side 
of New York City, living in crowded apartments. The hygienic factor is, 
therefore, an important one. Sixty per cent, of these children died from 
gastric and intestinal disease. About 30 per cent, died from catarrhal dis- 
eases affecting the air passages, such as bronchitis, pneumonia, and tuber- 
culosis. The rest died from infectious diseases and surgical accidents. 



X-RAY OR KOENTGEN EAY IN" DIAGNOSIS. 

During the last few years radiographic examinations form a most 
valuable adjunct to our methods of diagnosis in infancy and childhood. 



16 DIAGNOSTIC SUGGESTIONS. 

The possibility of an instantaneous exposure any time of the day or night 
has minimized the difficulty which formerly existed in taking pictures of 
restless or very sick children. 

Eadiographic examination was formerly limited to the bony struc- 
tures; hence was utilized in the diagnosis and treatment of fractures and 
dislocations. In addition to diseases affecting the bony structures, it is 
now possible to differentiate a syphilitic periostitis from a rachitis. Sub- 
periosteal haemorrhages and structural changes occurring in scurvy are 
revealed. An early, positive diagnosis of acute miliary tuberculosis with or 
without calcification of the glands can be made. 

Stomach conditions are now universally studied by radiographs of the 
alimentary tract, after the administration of some insoluble substance, 
as the bismuth salts, which obstruct the Eoentgen ray. Pyloric spasm and 
pyloric stenosis can easily be differentiated, the importance of which is 
apparent, before the aid' of the surgeon is called. 

Exudations, effusions, and transudations in obscure cases of empyema, 
intra-abdominal or thoracic effusions can be diagnosed. The presence of 
obscure neoplasms, a tumor in thei brain, the spine, or in any of the 
larger viscera can be made out with the aid of the x-ray. In a case seen 
recently, hypernephroma involving the left kidney was easily located by 
this means. A calculus in the kidney, ureter, or urethra is quickly located. 
Structural changes in the bones and congenital defects hitherto unsus- 
pected can be found. 

In diseases of the mouth and jaw affecting the teeth or the antrum 
of Highmore and in frontal sinus infections we can receive valuable assist- 
ance. It is too early to predict the possibilities of the therapeutic value of 
the x-ray, but the diagnostic aid rendered is indisputable. 



CHAPTEK V. 

GENERAL HYGIENE OF THE INFANT. 

Hygiene of the Mouth and Teeth. 

Mouth. — Care should be bestowed on the mouth and teeth. The new- 
born baby should receive an occasional washing of its mouth with a weak 
solution of boric acid and water. This should be done very carefully and 
gently, or the delicate floor or roof of the mouth will be denuded of its 
epithelium and invite infection. 

Bednar directed attention to the presence of aphthae due to trauma- 
tism. (See "Bednar's Aphthae.") 

The Teeth. — When teeth are present they should be kept clean. It is 
especially advisable to have the teeth cleaned with a weak alkaline solu- 
tion, such as bicarbonate of soda in water. Neglect of the teeth will result 
in caries and foul breath. A dentist should be consulted if there is the 
slightest evidence of decay. The necessity for healthy teeth is very appar- 
ent in infancy and childhood. A practical method of cleaning the teeth 
of children is to use a pinch of table salt in lukewarm water. 



The Management of the Navel (Umbilicus). 
The Umbilical Cord. 1 

If the child is in a good condition and is not blue (cyanotic), and if 
the pulsations of the umbilical cord have ceased, then the cord can be tied 
about one or two inches from the child's body. If the child is feeble we can 
gain by waiting for a few moments as we admit oxygenated blood through 
the umbilical vessels into the child's body. The point to be remembered 
is "to. tie the cord if the pulsations therein have almost ceased." This 
usually takes from two to five minutes. 

Some authors, e.g., Professor Epstein, advise making a gauze pouch 
resembling a small tobacco pouch to tie the cord. This can be easily ster- 
ilized by baking in an oven about thirty or forty minutes. Care must be 
taken that the heat is not too great or the gauze will be burnt. 

Do Not Use Oil or Salves. — When salves or oils are used they exclude 
the air and prevent the drying of the umbilical cord, which is so desirable. 
In order, therefore, to admit a current of air through the gauze to the cord, 



Diseases of the umbilicus — haemorrhages, etc. — are described in Part II. 

(17) 



18 GENERAL HYGIENE OF THE INFANT. 

nothing greasy should be used. The best thing to use is arrowroot or corn- 
starch or a talcum powder containing 1 per cent, of salicylic acid. 

The following two prescriptions are recommended as drying powders : — 

IJ Talcum 100 grains. 

Salicylic acid 1 grain. 

Mix and apply thoroughly every morning. 

Ifc Talcum 100 grains. 

Boric acid 1 grain. 

Use as above stated. 

If the child's condition is normal and healthy action takes place, then 
the cord usually falls off in about five to ten days. 

After-treatment. — The after-treatment consists in sprinkling one of 
the above-mentioned drying powders, and covering the region of the um- 
bilicus with several dry layers of plain sterilized gauze, over which an 
abdominal binder should be placed. 

An excellent powder is sold in the shops under the name of Velvet 
Skin Powder. It contains the following ingredients : — 

Boric acid 1 gram. 

Lycopodium 0.5 gram. 

Orris root 7.5 grams. 

Boro-tannate of aluminium 0.25 gram. 

Talcum q. s. ad 100 grams. 



Vernix Caseosa. 

The child at birth is covered with vernix caseosa. It is Nature's 
lubricant to protect the infant from the change of temperature prior to 
and after birth. 

It is advisable to lubricate the body with olive or sweet- oil. This will 
soften and remove the vernix caseosa. This can be continued daily until 
the cord has fallen off. 



The First Bath of the New-born Baby. 

The ease with which an infection can take place through the umbilical 1 
vessels accounts for most authors advising against the first bath being given 
until the umbilical cord has separated from the body. After the cord has 
separated and there is no evidence of inflammation or suppuration in the 



1 For disease of the umbilicus read Part II, Chapter on "Umbilicus. 



BATHING THE BABY. 19 

region of the umbilicus, then the first bath may be given. This is usually 
about the end of the first week. 



Bathing the Baby. 

The temperature of the bath for a new-born baby should be warmer 
than the baths given as the child's age progresses. It is advisable to bathe 
a new-born baby in water having a temperature between 95° and 100° F. 
To determine the temperature of a bath it is necessary to have a bath ther- 
mometer. One having a wooden casing is preferable. 

We should never guess at the temperature of a bath. Sometimes a bath 
that feels very hot to a sensitive skin may not be as warm as we imagine ; 
hence, the rule should be, "depend on the thermometer/' The temperature 
of the bath should be lowered or made cooler as the infant grows older. 

The temperature can be lowered five degrees from month to month until 
the bath is given at a temperature of 75° F. This is a tepid bath which can 
be continued during both winter and summer months for the first year of 
life. 

Additional Cleanliness. — It is self -understood that every infant requires 
additional sponge baths to keep its buttocks and genitals clean, especially 
so after each bowel movement. If a child is properly washed or sponged 
it is not necessary to overdo the use of soap. 

The Use of Soap. — Excessive use of soap will provoke eczema. Soap 
acts as an irritant to the skin if overused. There are some bland soaps 
which, if used in moderation, will do good; thus, the ordinary olive-oil 
soap, commonly known as castile soap, or the ordinary glycerine soap found 
in drug stores is very good. Medicated soaps are of no value for a new- 
born baby unless some special form of soap is required in a skin disease. 

After the Bath. — The child's body should be thoroughly dried and 
powdered, especially in the folds of the skin between the thighs, in the arm- 
pits, around the neck, the back, and the abdomen. We should use powder 
very liberally, as the dryer the skin is kept, the less chance will there be for 
the development of an eczema. 

Sensitive Skin. — If an infant's skin shows a tendency to be red and 
chafed it is advisable to use no soap at all, but an ordinary bath or an 
oatmeal bath made in the following manner will be found advantageous : — 

Oatmeal Bath. — How to make the oath: Take between two and three 
pounds of good oatmeal, and sew into a bag made of cheesecloth. Place the 
bag with the oatmeal in the infant's bathtub, containing one-half the quan- 
tity of water to be used for the bath. After the bag has soaked for about 



20 GENERAL HYGIENE OF THE INFANT. 

one-half hour, add enough water to bathe the child's body therein. The 
duration of the bath shall be about five to ten minutes. After the bath dry 
the body thoroughly and apply the following ointment wherever the skin is 
tender : — 

I£ Calaminaris 5 parts. 

Zinc ointment 50 parts. 

Apply with a piece of clean gauze over the affected parts. Do not use 
the fingers for applying the salve. 

When to Stop Bathing. — It is advisable not to bathe if an infant has 
an eczema or a very reddened skin, and it is a good rule to follow never to 
bathe if an eruption of the body is present, unless such eruption is due to 
an irritation applied to the skin. Turpentine, mustard, and camphorated 
oil, when rubbed into the skin, will cause an eruption resembling scarlet 
fever. Under such conditions the bath may be used; when fever appears 
the bath may be continued, providing there is no eruptive disease like 
measles or scarlet fever, and then even the baths may be given if the attend- 
ing physician so desires. When children have a cough or during catarrhal 
manifestations, it may be advisable in some instances to discontinue the 
bath for a day or two. Great care should be used while bathing a child 
suffering with vulvo-vaginitis to avoid infecting the eyes. 

Clothing. 

In New York and similar climates children should be comfortably 
clad. The body should never he overheated. The trouble usually found 
is that children are coddled and their bodies overheated by an excess of 
flannels. I have frequently had occasion to treat eruptions similar to the 
lichen tropicus which was produced by an excessive amount of clothing and 
consequent perspiration. 

The body should be well protected in winter, and very loose, light 
clothes should be worn in summer. No infant should be strapped tightly, 
but due allowance must be made for respiration and for the normal exercise 
of the infant, namely, by permitting freedom of the limbs. No pressure 
should be permitted on any portion of the body, so that the circulation is 
not impeded. Displaced organs can result from very tight fitting bands. 

The Feet. — The feet should always be protected. I do not approve of 
hardening infants by exposing their bare legs to the peculiarly changeable 
climate of our Atlantic coast. I have frequently' found digestive disturb- 
ances which could be attributed to cold feet. 

The usual shoe found in the shops for the new-born infant, as well as 
the first walking shoe, are simply ornament's and not practical shoes. It is 
advisable to devote at least enough care to have the shoes made on anatomical 



THE NURSERY. 21 

lines. The accompanying illustration (Fig. 7) shows the proper shape 
for the first walking shoe. 

The Abdominal Band. — The belly-band is a source of great anxiety to 
the mother. Its support is valuable for the umbilicus when the child is 
troubled with constipation or diarrhoea. It is a valuable support for the 
abdominal muscles if the child is affected with whooping-cough. It is not 
necessary to wear the band as an abdominal support more than three months. 
Delicate infants, premature infants, or those suffering with gastrointes- 
tinal disturbances may require a supporting bandage for a much longer 
time. 

Night Clothing. — Due allowance must be made for seasonal changes, 
so that light clothing should be worn in summer and a heavier set in winter. 
Eestlessness will frequently be induced by having the body too warm. 




Fig. 7. — Proper-shaped Shoe for Infant. 



The Nursery. 



To develop an infant we require fresh air and sunshine. We must 
only compare a flower deprived of sunlight and air to that which is devel- 
oped in ordinary healthful surroundings. An infant should be given 
the best room in the house, with a southern exposure. The reverse is usually 
found; infants are put into the smallest room, as though they were in the 
way. The nursery should be cheerful and sunny, and have a temperature 
ranging between 66° and 72° F. At night, when the child is well covered, 
the temperature may be lowered to 60° F. without hurting the infant. 

Ventilation. — This is one of the most important matters to be consid- 
ered during the development of the infant. An infant should invariably 
be removed from the room in which it has slept, and the windows of the 
nursery should be opened both top and bottom. After proper ventilation 
the windows are closed and the infant may be brought back again. The 
nursery should be ventilated at least two or three times a day. 

When to Take an Infant Out of Doors. — An infant one month old 
should be taken out into the fresh air in summer, sometimes sooner. It is 
understood that the first few times a child is taken out of doors it should 
be taken into the sun, if possible, for one or two hours. On rainy days or 
when it snows I invariably insist on giving the infant air by throwing 
open the windows and dressing the child with coat and cap as though it 



22 GENERAL HYGIENE OF THE INFANT. 

were to be taken into the street. This can be done for half an hour in the 
morning and afternoon. 

The Nursemaid. — The selection of a nurse is not an easy matter. That 
it is an important matter we can see when we consider cases of tuberculosis 
and syphilis that have been unquestionably transmitted by the nurse to the 
child. My rule is to exclude a nurse who surfers with catarrh or throat 
trouble. They are a constant menace to a healthy child. Specific rules 
should be given by the family physician to each nurse regarding the feed- 
ing, bathing, and general hygienic management. I invariably advise against 
nursemaids kissing children on the mouth. They should never be per- 
mitted to sleep in the same bed. I have known more than one case of uro- 
genital discharge transmitted to a female infant in this manner. I prefer 
a nurse between 20 and 40 years of age, one that is quiet, mild mannered, 
and that does not "know .everything." Experimental feeding, as is fre- 
quently tried by that miserable creature known as the "experienced nurse," 
is responsible for more rickets and weak children than any other method of 
rearing children. It is the mother's duty to consult the physician at least 
once a month or oftener regarding details of feeding, etc., and it is the 
mother's place to instruct the nurse. A mother who is dependent on a nurse 
will find that fact to be a detriment to her child. 

Method of Heating. — An open-grate fire or a Franklin radiator afford 
the best means of heating. Our city apartments in New York are furnished 
with steam heat, and a great many have gas heating. These latter are the 
worst forms of heating and are responsible for more catarrhal affections of 
the air passages than anything else. I invariably advise the use of a kettle 
with steaming water to add moisture to a room in which a gas stove or steam 
radiator is found. 

The air should be kept as fresh as possible; soiled diapers or soiled 
clothing should never be dried in the nursery. Smoking in the nursery 
should not be permitted, and kitchen odors should not be allowed to reach it. 

Light at Night. — To insure proper repose there should be no light and 
no noise in the nursery. With modern conveniences, such as electricity, a 
small, green, glass bulb can be used when a light is necessary. A wax night 
candle will answer for all purposes at night if electric light cannot be used. 

The Furniture. — The simpler the furniture the better. The ease with 
which infants and children contract measles, scarlet fever, and diphtheria 
shows the necessity for plain furniture and no useless overhangings. If the 
physician will explain to the mother that pathogenic bacteria will remain 
for months in carpets and rugs and tapestries, she will understand why 
simpler means are required. It is advisable, if possible, to have a hard- 
wood floor which may be scrubbed thoroughly. All rugs should be aired 
daily, and it is safer to fumigate the same with formaline when occasion 
requires. 



EXERCISE. 23 

The Bed and Pillow. — A cradle that can be rocked should never be 
used for a child. Nothing worse than a feather bed can be imagined ; still, 
I see them frequently. The best thing for an infant to sleep on is a hair 
matress, and by all means a hair pillow. 

Peoper Training. 

From earliest infancy it is advisable to train the baby. It should be 
given the breast, and after it is through nursing or feeding from the bottle 
it should be laid in the crib. If this habit is commenced early, a regular 
habit of resting can be formed. If, on the other hand, we permit the 
infant to sleep next to its mother's breast, it will get into the habit of being 
fondled to sleep. Bad habits will compel the mother to be a slave to her 
child, and wise is she who will accept the honest, well-meant advice of the 
physician regarding regularity in habits. 

Bowels. — An infant nine months old can be put on the commode. The 
best time for the infant's bowels to move is after the morning bottle. In- 
struct the mother to place the child on the chair, and if the bowels do not 
move naturally, assist the same by injecting about two ounces of water to 
which a few spoonfuls of glycerine have been added. This will aid in 
directing the infant's attention to its bowels. If the mother will do this 
regularly every morning the infant will gradually learn to known for what 
purpose it is placed on the chair. 

Bladder. — What is possible with the bowels can be accomplished with 
the bladder. If the mother or nurse will place the infant on a vessel every 
three or four hours, the infant will gradually learn to hold its urine until 
such time. The infant should be placed on the vessel immediately on awak- 
ening, be it night or day. Children invariably empty the bladder on 
awakening. 

Hygiene of the Nervous System. — To develop an infant's brain the 
nervous system requires quiet but cheerful surroundings. Useless excite- 
ment is harmful. To take an infant' and handle it like a toy is wrong. I 
have seen infants taken up from a sound sleep to display the "talent" that 
some one had taught them. Nothing is more harmful than to have the 
mother compel her infant to display various tricks during its feeding. While 
this may be a gratification to the friends, it certainly is detrimental to the 
infant's brain and nervous development. 

Physical Exercise. 

The health of the infant and child demands exercise. When this is 
neglected, disease results. Broadly spaeking, there are two forms of exer- 
cise — active and passive. There are limitations to active exrcise. In acute 
febrile conditions, rest is demanded, and all active exercise contraindicated. 
At such times, if necessary, massage may take the place of active exercise. 



24 GENERAL HYGIENE OF THE INFANT. 

Not only in acute inflammatory conditions, but also in eruptive diseases, no 
form of active exercise should be allowed. Recognizing the fact that 
violent exercise results in albuminuria, it is very important for the physi- 
cian to prescribe exercise and at the same time supervise its effect on the kid- 
neys by examination of the urine. It is important to bear in mind that in 
chronic kidney disease, as in acute congestion of the kidney, or following 
scarlet fever or typhoid fever, the resulting strain from violent exercise may 
do harm. 

What has been said concerning the kidney applies even more strongly 
to the heart. After an attack of scarlet fever or diphtheria, or even after 
pneumonia or influenza, the effect of the toxin usually weakens the myo- 
cardium. Exercise should therefore be prescribed very carefully, and the 
immediate effect on the heart noted. The effect on the blood-pressure, on 
the lungs, and on the body is watched, so that no strain is permitted. 

If dyspnoea, fatigue, or irregular heart action follows a mild form of 
exercise, then rest — not activity — is demanded, and here again passive 
motions aided by massage will be indicated. 

It is a well-established fact in physiology that an unused organ does not 
develop properly; that a period of long disuse leads to atrophy; that regu- 
lar exercise of an organ leads to its normal development and growth, and 
that organs that are exercised a great deal are, in most cases, hypertrophied. 
These structural changes are associated with the anabolic effects of exercise, 
and are most apparent in the nervous and muscular tissues, in the heart, 
and in the tendons, ligaments, connective-tissue sheaths, bones, and joints 
associated with the voluntary musculature. It seems to be true also that, in 
certain tissues at least, exercise not only increases the size of the individual 
element (muscle fiber, for instance), but also increases the number of the 
tissue elements present, so that there are more muscle fibers in the regu- 
larly exercised muscle and more nerve cells in the regularly exercised motor 
center than in those muscles and centers that are not regularly exercised. 

Associated with its beneficial influence upon general metabolism, 
physical exercise causes a general increase in the functional efficiency of the 
organ. The heart develops a greater strength, regularity, and endurance. 
Circulatory activities are improved. The depth of inspiration is increased. 
The rhythm of respiration is slowed. The strength, endurance, and co- 
ordination of the neuromuscular elements controlling the movements of 
respiration are improved. The necessary and very intimate co-ordination 
between the complex respiratory machine, the complex circulatory machine, 
and the complex vasomotor machine is brought into more perfect adjust- 
ment and efficiency. The heat regulation of the body is improved. Diges- 
tion, metabolism, and excretion are improved. 

The production of active or potential immunity is a function of some 
of the fixed and circulating cells of the body. When pathogenic organisms 



EXERCISE. 25 

within certain limits of virulence gain access to the tissues they are 
destroyed or rendered innocuous by one or more of several processes. On 
the cells of the body depends the exhibition of the phenomena of immunity. 
The degree of immunity produced is related directly to the health of the 
cell. An impoverished, poorly nourished, unhealthy cell will not react to the 
same extent and with the same success as will the normal, healthy, well- 
nourished cell. 

The health, and, therefore, the immunity-producing power, of the cell 
depends upon its nourishment, including food, water, and oxygen; upon its 
relief from the toxic influence of its own waste products; upon its exercise, 
upon its opportunities for rest and repair, and upon a reasonable freedom 
from the direct and indirect influences of pathogenic organisms. The 
health, and, therefore, the immunity, of the w r hole body depends upon the 
health of all its constituent parts — on the health of its cells. If the cells are 
all well nourished, active, and protected from extremes of pathogenic influ- 
ences, their summated health will be the health of the individual whose 
body they in combination make. That such a healthy individual is pos- 
sessed of a certain degree of immunity has been proven empirically and 
experimentally, and it is equally well established that the possession and 
conservation of the healthy body depend upon the observance of several 
simple hygienic procedures. 

The above statements, made by Dr. Thomas A. Story, are founded upon 
physiological and clinical study. Exercise is demanded in health and is 
necessary to stimulate metabolism of the food elements, and also to aid in 
the assimilation of food. External exercises are voluntary and are de- 
manded to stimulate the circulatory, the muscular, and the glandular 
systems. 

The activity of the internal secretions depends on the proper exercise 
of the body. Lack of exercise and the lack of peristaltic waves are best 
seen by the resulting constipation. 

In health the variety and quantity of exercise indicated depend upon 
the age, sex, habits, physique, and conditions of the individual. The infant 
must have freedom for the kicking, squirming, grasping, and twisting move- 
ments that develop his musculature, incite and perfect his larger co-ordina- 
tions, and stimulate his whole organism to normal functional activity. 

The growing child continues these absolutely essential influences 
through his play, games, and sports, and secures these physiological benefits 
more or less completely in spite of the restrictions of the home, the_ school, 
and urban life. 

If the infant is bound fast, he does not grow. If the child is forced 
to lead an absolutely sedentary or bedridden life, he does not develop. 

I am indebted to Dr. Thomas A. Story, Physical Director of the College 
of the City of New York, for many valuable points in this article. 



PART II. 

ABNORMALITIES AND DISEASES OP THE NEW-BORN. 



CHAPTER I. 



PREMATURE INFANTS. 



An infant born before 280 days of intrauterine life is called premature. 
Some authors maintain that infants weighing less than 4 pounds should 
be considered premature. If the length of the body is less than 19 inches, 
then we may suspect prematurity. The internal organs, especially the lungs, 
not being fully developed, we cannot expect normal functions. A premature 
infant does not cry but whines. There is muscular inertia. The circulation 
is very poor and there is a subnormal temperature ranging between 88° and 
96° F. 

Children born at six and a half months have grown up strong at last, 
although it is not often they survive if born before the seventh month. The 
great need of such a baby is heat/ and the maternity hospitals employ an 
apparatus, called a couveuse, brooder, or incubator, especially devised to 
supply it. 

For family use a couveuse may be bought at the instrument makers, or 
hired from some of them. This is perhaps better, as the apparatus is costly. 
With an increased degree of attention we may get along fairly well without 
it. If a premature baby is bathed at all after birth, the temperature of the 
water should be 105° F., and the greatest care should be taken, while drying, 
to see that the child is not chilled. It should be made very warm by swad- 
dling it in raw cotton, head and all, leaving only the face exposed, wrapping 
it about with a blanket, and tying it around with a roller bandage. Hot- 
water bottles should be placed on each side of it as it lies thus wrapped up 
in its bed, and fresh ones substituted frequently. A very convenient method 
is. to place the child in a baby's bathtub half-full of raw cotton, in which a 
number of hot bottles have been concealed. 

The infant's only clothing consists of a diaper and a shirt. The room 
should be kept warm, and especially so when this human bundle is un- 
wrapped for its bath. After bathing it should be rubbed with sweet-oil and 
rolled up again in fresh cotton. Often it is better to omit all bathing, and 
simply rub with the oil. These premature infants lose considerably more 
in proportion to their birth weight than babies at term. This is due to 
their immature digestive tract; also to the fact that they are almost always 
intensely jaundiced. They gain very slowly; if at the end of two or three 
weeks they have reached their birth-weight, they have done unusually well. 
(26) 



THE CARE OF PREMATURE INFANTS. 



27 



The incubator here described (see Fig. 8) is the one used at the 
Sloane Maternity Hospital. There is a great variety of these incuba- 
tors, but the one made by the Kny-Scheerer Company in New York 
City will answer all re- 
quirements. Owing to 
its expense, the manufac- 
turers will lend an incu- 
bator for a nominal sum 
per month. 

The apparatus is 
constructed of steel, with 
glass doors and one glass 
window on the side for 
feeding purposes, etc. 

The heat is gener- 
ated by electricity and 
can be regulated to any 
desired temperature. The 
electric thermostat is sus- 
pended from the ceiling 
of the chamber. At its 
left end is a thumb- 
screw, which regulates the 
amount of heat. Under- 
neath the cradle and 
above the heater is a 
water pan, which should 
be well filled with water. 
This is to supply mois- 
ture to the air in the 
apparatus, the amount of 
which is recorded by the 
hygrometer attached to 
the rear wall. The air 
supplied to the infant is 
filtered through an absorb- 
ent cotton filter. This air 
can be taken from the 
room in which the apparatus is placed, or directly from the outside by 
means of simple tubes. The revolving wheel in the chimney indicates the 
perfect circulation of the air. This apparatus can also be supplied with a 
gas heat-generator, the electric being preferred in order to minimize the 
contamination of the air. 




Fig. S. — Incubator made by the Kny-Scheerer 
Company, New York. 



28 ABNORMALITIES AND DISEASES OF THE NEW-BORN. 

In some of the babies the color is poor from the beginning, and at any 
time they are liable to attacks of cyanosis. For these conditions a little 
slapping to cause a good cry or the administration of oxygen will dissipate 
the blueness. Often a few drops of brandy in water given every two or three 
hours will prevent further trouble. One must be very sure, however, that 
nothing has been aspirated into the larynx (Griffith). 

A great danger in the care of these babies is their susceptibility to 
infections. The incubator itself is a great germ carrier and should be 
regularly disinfected. The weakness of the lungs and gastro-enteric tract 
makes the infant especially vulnerable. Unless the air is filtered, dirt is 
carried in continuously; consequently, the streptococcus, staphylococcus, 
and pneumococcus are always present, seeking an avenue of entrance, 
through the skin in eczematous spots or in areas of irritation, at the navel, 
through the eyes, nose, mouth, larynx, lungs, stomach, and rectum, the 
bacteria can gain admission. To prevent infection the most careful cleans- 
ing is necessary, of both the incubator and the baby. Undoubtedly most of 
the deaths of our cases could be traced to this source. 

A Danger of Incubators. — An infant placed in an incubator was found 
dead one morning, suffocated by vomited milk drawn -into the lungs. To 
prevent this catastrophe Wormser suggests that infants should not be re- 
placed in the incubator until a certain interval has elapsed after feeding. 
E. Wormser (C entrdlblatt f. Gynakologie, No. 38). 

Finally, in the carrying out of the above essentials in the proper man- 
agement of the premature infant, we require the most patient and pains- 
taking attention on the part of the nurse, and upon her conscientiousness 
depends the chance of its survival. 

Eesults. 

The statistics are taken from 2314 births which occurred at the Sloane 
Maternity Hospital. 

Four hundred and ten of these babies were premature, but of these 74 
were stillbirths, which include macerated fetuses and stillborn cases of pla- 
centa prsevia, accidental haemorrhage, eclampsia, and the like, leaving 336 
for treatment. 

Among these cases was a set of triplets, and there were 18 pairs of 
twins; 85 were treated as infants at term, and of these 4 died — a mortality 
of 4% P e r cent.; 145 were put in cotton, and of these 12 died — a mor- 
tality of 8 per cent. Some of this class should have been placed in the 
incubator, but for lack of room it was impossible ; 106 were incubator babies. 

These are divided into two classes: — 

1. Those that died within 4 days after birth. 

2. Those that lived longer than 4 days. 

Twenty-nine of the incubator babies died within 4 days. All of these 



PLATE II 






Incubator Bed designed by Dr. Julius H. Hess, of Chicago. Well adapted for 
premature infants. Its use in the Michael Reese Hospital has demonstrated its 
practical value. Cross section: Jf, copper wall covering asbestos layer; 9, stand 
supporting bed; 11, and l't, inner and outer walls of copper water jacket; 12, asbestos 
layer insulating water jacket; 15, water within jacket surrounding sides and floor 
of bed; IS, water gauge; 10, plug in opening used for filling jacket; 20, cock 
for emptying jacket; 22, removable crib; 24, air space underneath crib; 26, heating 
plate; 28, rheostat; 29, electric plug. 



THE CARE OF PREMATURE INFANTS. 29 

were more or less asphyxiated at birth ; 9 were breech cases, and of these 5 
were difficult extractions; 3 after an accouchement force in placenta prcevia. 
The rest were vertex presentations, and of these 2 were forceps deliveries; 
6 were under 7 months of uterine gestation; 22 were between 7 and 8 
months, and 1, 8*4 months. 

The etiology of the premature labor was an endometritis in 14 ; syphilis 
in 2 ; albuminuria in 1 ; placenta praevia in 3 ; accidental haemorrhage in 
1 ; persistent vomiting in 1 ; twin in 1 ; violence in 1, and in 4 the labor 
was induced. The largest baby weighed 5% pounds; the smallest 2%6 
pounds. Only 5 infants lived over 24 hours; 24 were in such poor condi- 
tion at birth that they survived only a few hours. In 16, autopsies were 
held, and in all of these there was marked atelectasis; in 7 there were 
haemorrhages of some degree, either into the brain or into the serous mem- 
branes; in 2 the foramen ovale was still patent. 

Seventy-seven incubator infants survived the first 4 days; 51 were 
children of primiparae, 27 of whom were out of wedlock; 3 infants were 
under 7 months of gestation ; 8 were over 8 months ; 9 were breech presen- 
tations; 1 a transverse, and the rest vertices; 2 were of triplets associated 
with albuminuria; 18 were in twin deliveries associated with albuminuria 
or hydramnios. The cause of the premature labor was endometritis in 27 ; 
syphilis in 4 ; phthisis in 2 ; albuminuria in 7 ; accidental haemorrhage in 
1 ; placenta praevia in 1 ; in 2 the labor was induced for albuminuria and 
eclampsia; 1 was a Caesarean section; another an ectopic gestation by a 
laparotomy; 12 were slightly asphyxiated at birth, 9 moderately so, and 5 
deeply asphyxiated; 2, after one and one-half hours' work of resuscitation, 
were put in the incubator head downward, and their condition was so poor 
that they were not expected to live, but they left the hospital gaining in 
weight; 5 weighed less than 3 pounds; 38 between 3 and 4 pounds; 33 
between 4 and 5 pounds; 1 over 5 pounds; the average weight was 3% 
pounds. During their incubator life 28 had one or more attacks of atelec- 
tasis. All but 10 were more or less jaundiced. The initial loss of the 
infants was from 1 to 17 1 /2 ounces; the average was 7 ounces. 

These figures are not quite correct, as the babies were weighed at dif- 
ferent intervals, some on the fifth day, some on the seventh day, and some 
not until the fourteenth day. 

The period of loss was from 5 to 22 days; the average 11 days; 10 lost 
steadily until death ; 1 baby was in the incubator only 3 days, while another 
lived there 82 days. The average time was 19 days. Some were removed 
early to make room for others who needed the place more urgently. 

Only 3 of the 77 cases vomited. The stools were normal in 32. 

One was discharged from the hospital as early as the eleventh day, 
and others, also, too soon at their mothers' demand. One was 89 days old ; 
the average was 24 days. 



30 



ABNORMALITIES AND DISEASES OF THE NEW-BORN. 



In 16, diluted breast-milk was supplemented at times with a mixture 
of cows' milk and water, with Eussian gelatine and lactose. In 10, a 1, 6, 
0.33 1 modification was used. In all the rest diluted breast-milk was relied 
upon. Twenty-seven never nursed at the breast; of these 12 died. A few 
nursed as early as the third or fourth day two or three times daily; others 
not for three weeks, and 1 not till the sixty-eighth day. Of the 77, 13 died in 
the hospital — a mortality of 16 per cent. The cause of death was atelectasis 
and bronchitis in 7 ; acute asphyxia from a curd in the larynx in 1 ; syph- 
ilitic pneumonia in 1 ; cerebral haemorrhage in 1 ; gastro-enteritis in 3, 
and a patent foramen ovale and ductus arteriosus in 1. The condition of 
3 was poor at the time of discharge, fair in 24, and very good in 37; 32 
were above their birth-weights, and 57 were gaining in weight. To letters 
written about January 1, 1900, no answer was obtained from 28. Thirteen 
were reported as having died; 1 of these lived 14 months; 1 lived 4% 
months ; 3 lived 2 months ; 6 lived 6 weeks ; 1 only a month. Five of these 
died at the Nursery and Child's Hospital, and 2 died at Bellevue Hospital. 
They were bottle-fed, and the probable cause of death was gastro-enteritis. 

Twenty-one were found to be alive and doing well. Some had nursed, 
and the others were bottle-fed. The oldest baby was 22 months, and almost 
all were good, healthy children. One baby at 7 months weighed 16 pounds. 
It weighed 4% 6 pounds at birth, and nursed from its mother after leav- 
ing the hospital. The ectopic and the Cesarean babies were in beautiful 
condition. 





Table No. 7. 






Incubators. 


Tarnier. 
Per Cent. 


Charles. 
Per Cent. 


Sloane 
Hospital. 
Per Cent. 


At the Sloane Hos- 
pital. Not Counting' 
Those which Died in 
a Few Hours. 
Per Cent. 


Saved at 6 months 

Saved at 6 J months 

Saved at 7 months 

Saved at 7 1 months. ..... 

Saved at 8 months 


16, 
36 
49 

77 
88 


10 
20 

40 

75 


22 
41 
75 
70 


66 
71 
89 
91 



Method of Feeding. 

The size of the child precludes the taking of an ordinary nipple ; hence, 
various measures have been tried, the most successful of which has been, 
according to the author's experience, feeding with Dr. Breck's feeder for 
premature infants (see Fig. 9). Feed at intervals of one hour, the quan- 
tity varying with the age of the infant 



Fat, 1; sugar, 6; proteins, 0.33. 



THE FEEDING OF PREMATURE INFANTS. 



31 



A prematurely born baby is certainly doomed without ^proper food, 
and there are so many other factors to be considered during its life in an 
incubator, such as ventilation, its bodily warmth and cleanliness, that too 
much stress cannot be laid on the value of its food. Without oreast-miTk, 
therefore, I feel justified in saying: I have yet to see the premature infant 
that will survive, and hence I advise procuring oreast-miTk, containing no 
colostrum-corpuscles, but from a woman having a child anywhere between 
two weeks to several months old, and diluting this breast-miTk, as stated 
above, with a solution of milk sugar or cane sugar. 

Voorhees 1 says: "Kegarding the care of premature babies in incu- 
bators, Ave have relied mainly on diluted breast-milk, and have only 
employed diluted cows' milk in weak proportions when it was impossible 




Fig. 9. — Dr. Breck's Feeder for Pre- 
mature Babies. Can be made with a 
medicine dropper to which a nipple is 
attached. 




Fig. 10.— (a) Funnel. (&) Rubber 
Catheter, (c) Glass Connecting Tube. 
(d) Rubber Tube and Stopcock. 



to obtain the former. In our opinion our results would have been much 
poorer without the help of mothers' milk." 

In rare instances, when infants are very weak and seem to doze and 
will not swallow, they should be fed with a No. 8 American (Tiemann & 
Co.) rubber catheter attached to a rubber tube about one' foot in length 
and ending in a funnel. (See Fig. 10.) 

Very small quantities of food should be used in gavage-feedings of the 



Archives of Pediatrics, May, 1900. 



32 



ABNORMALITIES AND DISEASES OF THE NEW-BORN. 



mouth or when feeding through the nose. No more than 4 to 6 drachms 
should he used, and thus we can feel our way. It is a good point to remem- 
ber that the pharynx being very sensitive, the irritation of the tube passing 
into the stomach may provoke regurgitation of some of this food, and fre- 
quently vomiting will be produced. 

Baby M., born March 31, 1909, was sent by Dr. I. L. Hill to my service in 
the Babies' Wards of the Sydenham Hospital. The weight at birth was five pounds 
two ounces. The feeding consisted of mother's milk three drachms diluted with 
barley water three drachms. On April 2d, when three days old, the weight was 



K^SdyJtt 


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SYDENHAM HOSPITAL 

Age..'. ... » WEIGHT CHART - Dak 


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Fig. 11. — Birth: | Placed in Incubator; J, Removed from Incubator. 

five pounds. The infant could not retain the diluted human milk, there was con- 
siderable projectile vomiting. Condensed milk was then given. Condensed milk 
Va drachm to two ounces of sterile water. One-half ounce was given at each feed- 
ing. This food was retained but the infant emaciated and its lowest weight was 
four pounds. Gavage was resorted to at every other feeding. The vomiting became 
less and the weight increased, the infant gaining slowly. The extremities were cold. 
The infant was cyanosed and was placed in an incubator. It then weighed four 
pounds four ounces. As the weight remained stationary for one week, the condensed 
milk feeding was discontinued and two drachms of the following formula were 
given: Cows' milk, 30.0; barley water, 50.0; peptogenic milk powder, */, measure. 
The infant gained rapidly, vomited less, and slept longer. Whenever possible 
we procured woman's milk and substituted it for the cows' milk feeding. The 
infant remained in the incubator twenty-seven days, and was removed weighing 
six pounds seven ounces. 



THE FEEDING OF PREMATURE INFANTS. 33 

The Stool. — From meconium at birth, the stool gradually become a grass-green, 
jelly-like mass; later it was a yellowish-green, saponified stool. The first three 
weeks the infant was constipated. This constipation later improved so that the 
stool was softer, pasty in consistency, and yellowish or yellowish-green in color. The 
infant grew and developed and was discharged in June, 1909, weighing eleven 
pounds. 

Serum Injections. — The subcutaneous injection of sterile horse serum was com- 
menced with the idea of promoting nutrition. About 15 cubic centimeters were 
injected into the loose cellular tissue of the abdomen, and, when it was found that 
it was completely absorbed, a daily injection of 15 cubic centimeters was ordered. 
Later 30 cubic centimeters were injected and absorbed. No febrile reaction fol- 
lowed such injection. Although many dozens of these injections were given, with the 
usual aseptic precautions, not once did an abscess or other sign of infection occur. 

The gradual daily increase in weight was attributed in some measure to this 
mode of treatment. 

Skimmed milk has given me excellent results in a series of premature 
infants. Whenever possible the mouth feeding was supplemented by hypo- 
dermoclysis consisting of 2 ounces of normal saline solution, temperature 
103° F., injected twice a day into the loose cellular tissue of the abdomen. 

A close study of the details required in the successful rearing of 
undersized infants shows that the following points are helpful : — 

1. Vomiting, if present after feeding, means longer interval between 
meals. 

2. An undeveloped and weak infant taking but several drachms from 
a medicine dropper will be better fed by gavage. Most of my success has 
been due to gavage at regular intervals night and day. 

3. The temperature of the infant is usually subnormal. In addition 
to placing the infant in an incubator, I have its body well oiled, especially 
the feet, and the infant wrapped in cotton. The heat of the incubator 
produces dryness of the mouth and lips, therefore water is given frequently 
by spoon or mediciue dropper. 

4. To aid metabolism and to assist the bowels, an injection of a table- 
spoonful of warm sweet oil into the rectum helps to move the bowels. The 
weight should be taken daily, and it is important to increase the percentage 
composition of the food until the infant gains in weight. 

5. The great danger of exposure prohibits the daily bath, hence the 
infant should be cleansed by inunctions with w r arm oil. 

The Incubator. — The strict supervision of an incubator demands two 
trained nurses. The heat must be regulated. The thermometer on the 
inside of the incubator must frequently be observed and the moisture 
properly regulated, so that the air in the incubator is not too dry. 

As a rule, an incubator infant, if otherwise healthy, shows restlessness 
when its feeding time arrives. The infant is taken from the incubator, the 
doors of the incubator are closed to retain the heat, the infant is rapidly 
fed by gavage or the feeder, and returned to the incubator. 



CHAPTEE II. 

PROPHYLAXIS AND TREATMENT OF THE EYES IN THE NEW-BORN. 

The vaginal discharge of a pregnant woman contains pathogenic bac- 
teria. This frequently gives rise to an infections catarrh in the new-horn. 
It is therefore important to treat the eye of the new-born baby with 
extreme care to prevent an infection which can produce serious results. 

Treatment of the Eyes in the New-born. 

Ordinarily the eyes should be washed with a pledget of sterilized cotton 
dipped in plain sterile water or a 2 per cent, boric acid solution. The 
mouth and nose should be similarly treated. All cotton used for the hygiene 
of the mouth, nose, and eyes should be burned immediately after use. 

Crede advises the use of a 1 per cent, solution- of nitrate of silver. 
One drop (no more than one drop) is allowed to drop from a solid glass 
rod or a medicine dropper on the center of the cornea. Its object is to 
prevent the infant from acquiring ophthalmia neonatorum. 

The prophylaxis of blindness is worth studying. The New York 
Association for the Blind reports many cases "of needlessly blind victims 
of ophthalmia neonatorum." The official census of the blind for the 
State of New York for 1906 gives a total of 6200, out of which number 
1984 were preventable blindness, most of them caused by ophthalmia 
neonatorum. 

Garrigues 1 states that in lying-in asylums before this treatment was 
adopted, purulent ophthalmia was very prevalent. 

Statistics show that one-half to two-thirds of those affected with 
blindness lost their sight from this cause. 

When the frequency of the gonococcus in the vaginal secretions of 
women delivered in lying-in asylums is considered, then the wisdom of 
prophylaxis cannot be questioned. 

Of late protargol (10 per cent, solution) has been substituted for the 
nitrate of silver solution. It is just as effective and less irritating. 

Solution argyrol (20 per cent.) is very useful in the catarrhal affec- 
tions of infants and children. I have seen very good results during my 
service at the Willard Parker Hospital with the same. 2 



1 Henry J. Garrigues : "Textbook of Obstetrics," 1902. 
^See also Part.X, "Diseases of the Eye." 



(34) 



CHAPTER III. 
DISEASES AND MALFORMATIONS OF THE UMBILICUS. 

Granuloma. 

A mass of fungus or exuberant granulations is frequently found in 
the umbilicus. Sometimes the granuloma resembles a large red bead. It 
is usually seen after the cord has separated. A discharge usually oozes. 
These granulations bleed very easily. 

Treatment. — The application of a solid stick of nitrate of silver to 
thoroughly destroy the granulations is usually all that is required. If these 
granulations persist then the same can be removed with the aid of a sharp 
curette by simple scraping, after which a' dusting powder like europhen 
should be used. 

Diphtheritic Omphalitis. 

The new-born baby is occasionally infected with diphtheria. If there 
is an omphalitis the Klebs-Loeffler infection can easily be transmitted. The 
following case was seen by me in consultation : — 

A child 4 years old suffered with diphtheria of the upper air passages, which 
finally spread to the larynx, necessitating intubation. This family lived in a 
crowded apartment. The mother gave birth to an infant five days later, and was 
herself infected with diphtheria of the vagina and vulva. Her new-born baby 
was about six days old when I first saw it. The umbilical cord had just sloughed 
away. The region of the umbilicus was highly inflamed and covered with thick 
pseudo-membranes. The child died on the eleventh day, of septicaemia. A culture 
taken showed Klebs-Loeffler bacilli. The physician that attended this family told 
me that the nurse in charge of the older child with laryngeal diphtheria also nursed 
the mother and the new-born baby. He believed that the infection was undoubtedly 
carried by the nurse. 

Treatment. — Saturate a piece of sterile gauze with antitoxin and apply 
to the umbilicus. Eemoisten every hour, applying fresh gauze three times a 
day. Give an intramuscular injection of 1000 antitoxin units. Give % 
grain calomel twice a day for three days. 

The Dangers Incident to Carelessness in Handling the Navel. 

If through some accident the ligatures around the umbilical cord 
should slip, and blood oozes from the wound, fatal haemorrhage can result. 
The attention of the plrysician should at once be directed to this condition., 
This can become a very serious matter if neglected ; hence it is of the utmost 
importance to remedy it at once. The neglect of such things, besides the 

(35) 



36 



DISEASES AND MALFORMATIONS OF THE UMBILICUS. 



improper bandaging or uncleanliness in this region, is liable to cause not 
only convulsions, but blood poisoning and death. 




Fig. 12. — Case of Omphalocele admitted to the Babies' Wards of the 
Sydenham Hospital. A semi-globular tumor 4 inches in diameter, and 
2V 2 inches above level of the body. The stump of the umbilical cord is 
seen on the left side of the tumor. Sterile gauze dressings were applied. 
After several weeks the mass gradually sloughed off and the wound closed. 
( Original. ) 




Tig. 13.- — Appearance of abdomen four weeks after treatment, 
was discharged cured when six weeks old. (Original.) 



Case 



Septic Omphalitis. 
An infant was seen by me, through the courtesy of Dr. S. Straus, in 
this city during the summer of 1902. History, as follows : — 

It was the first child born; no previous miscarriage; family history excellent; 
no history of syphilis; labor was easy, and baby was born in natural manner. 
The mother was in excellent health; had milk in both breasts; normal temperature. 
Asepsis was thoroughly carried out. The infant had a temperature of 103° F., in the 
rectum, slight gastroenteric complication, greenish, colicky stools; the umbilicus 
was inflamed and excoriated; slight evidence of pus. 

Diagnosis. — Septic omphalitis due, probably, to infection by the nurse with un- 
clean hands while dressing the umbilicus. 

Treatment, — Strict asepsis to be followed. The umbilicus to be washed with 



CONGENITAL OBLITERATION OF THE BILE DUCTS. 



37 



1 to 2000 bichloride of mercury. Sterile gauze and aristol or some drying powder 
applied. The stomach and bowels were cleansed with calomel, and the infant fed 
every two hours at its mother's breast. The child made an excellent recovery in 
about four or five days. 

Meckel's Diverticulum. 
A condition which may at first simulate umbilical polypus, and for 
which umbilical polypus may be a symptom, is the persistence of a Meckel 
diverticulum. This consists of the persistence of a piece of intestine, 
usually patent, connecting the small intestine with the umbilicus. It rep- 
resents a vitelline duct that failed to atrophy when the placental circulation 
became established, and betrays its presence by an escape of faeces from the 
umbilicus. It is a rare malformation (Eotch). 





ar-* 



Fig. 14. — Illustrating Effects of the Persistence of the Omphalomesenteric 

Duct and Formation of the So-called Diverticulum Tumor (Riesman). 

1. The omphalomesenteric duct shown as an opening leading: from the umbilicus to the 
ilium. 2. Showing; a small portion of the proximal intestinal wall. This may happen in a 
constipated child, while straining at stool. The same condition may occur during: a par- 
oxysm of whooping-cough. 3, The tumor is much larger, frequently sausage-shaped. It 
is irreducible. 

Congenital Obliteration of the Bile-ducts. 

This condition has been carefully studied by John Thomson, of Edin- 
burgh. He has tabulated his studies in his book on "Congenital Oblitera- 
tion of the Bile-ducts," 1892, 

Etiology. — There can be no doubt that various malformations of the 
liver and bile-ducts do occur which are certainly of this nature. For 
example, congenital absence of the gall-bladder has been frequently de- 
scribed, and some of the cases were due to arrest of development, although 
many were probably of inflammatory origin. Wenzel Gruber has published 
a case in which a forked cystic duct was found, and Konitzky has described 
another in which the common duct had an unusually long and curved 
course, and opened into the middle of the horizontal portion of the duo- 
denum, its lumen being narrowed. 0. "VTitzel also has published notes of 
an infant born with a large number of congenital abnormalities, in whom, 
in addition to hemicephalus, situs viscerum inversus, six ringers on each 
hand, etc., there was a cystic condition of the liver and complete imper- 
meability of both the cystic and common ducts. Other developmental 
defects have been observed, namely, in Heschrs absence of the bile-ducts in 



38 DISEASES AND MALFORMATIONS OF THE UMBILICUS. 

the liver-tissue, and in Professor Simpson's want of the spigelian and quad- 
rate lobes. 

The frequency with which this exceedingly rare condition affects sev- 
eral members of the same family is very strongly in favor of this view, and, 
indeed, it seems difficult to explain it otherwise. It has been suggested that 
this reappearance of the disease in the same family might be explained by 
supposing a common syphilitic taint. This suggestion, however, cannot be 
accepted, for we never find a tendency for an extremely rare manifestation 
of syphilis to recur four or five times in a family without any of the com- 
mon symptoms of that disease being present at the same time. 

Pathology. — The liver is usually found much enlarged, of a very tough 
consistency — due to biliary cirrhosis — and of a dark green color, owing to 
the presence of numerous masses of inspissated bile in the small bile-ducts. 
In the great majority of cases there is complete obliteration of some part 
or parts of the hepatic, common or cystic ducts, or of the gall-bladder, 
while with very few exceptions, implication of the blood-vessels or other 
tubes in the neighborhood is conspicuous by its absence. 

Pathology of the Lesion of the Ducts. — The lesion has been ascribed 
to three different morbid processes, either acting separately or in combina- 
tion, namely: — • 

1. Peritonitis and its results, acting on the ducts from outside, and 
either compressing them or being a source of inflammatory action, which 
spreads afterward to their walls. 

2. An inflammatory or other lesion of the ducts themselves. 

3. An arrest or defect of development. 

And further, various predisposing causes have been described as 
accounting for these morbid processes, namely : — 

1. Congenital syphilis. 

2. Digestive disturbance on the part of the parents. 

3. Injuries or exposure to cold, either of the mother or child. 

4. Erysipelas of the child. 

Symptoms. — Such children are jaundiced at birth or they become so 
within the first week or two of life; otherwise they are healthy and well- 
nourished. In some cases there is meconium followed by colorless motions ; 
in others the faeces are devoid of color from the very first. The urine is 
deeply bile-stained. The jaundice is of a dark greenish tinge, and lasts till 
death, and the motions remain colorless. A certain proportion of the 
children die from umbilical haemorrhage within the first fortnight, and, of 
those who survive this period, a large number surfer from spontaneous haem- 
orrhage from other situations. The liver steadily enlarges, and the spleen 
also. After living some months the children become more or less emaciated. 
Spasms often supervene, and death ensues in the end in a state of exhaustion 
from some trifling intercurrent disease.- 



CHAPTEE IV. 
HEMORRHAGIC DISEASES OF THE NEW-BORN. 

Spontaneous Hemorrhage. 

The occurrence of spontaneous haemorrhages is one of the most char- 
acteristic clinical features in these cases. In the cases collected by Thomson, 
in 21 out of the 50 — that is, in almost half of the cases which lived more 
than a few days — the fact of haemorrhages having occurred from some part 
of the body is noted, and in all probability it may have occurred in some 
of the others also, although not mentioned, as the records of many of them 
are so meager. 

The situations of the haemorrhages mentioned in Thomson's collection 
are as follows : — 

Subcutaneous in 7 of the cases. 

Subconjunctival in 1 of the cases. 

Umbilical '. .... in G of the cases. 

From nose in 2 of the cases. 

Vomited in 4 of the cases. 

From bowel in 8 of the cases. 

From mouth in 1 of the cases. 

From lung in 1 of the cases. 

Into gall-bladder in 1 of the cases. 

From leech-bite (excessive) .in 1 of the cases. 

A tendency to bleed is found in many children. In the preceding 
chapter I have described haemorrhage as a symptom of congenital oblitera- 
tion of the bile-ducts. 1 I have also described a very serious haemorrhage in 
a case of congenital syphilis (see chapter on "Syphilis"*) which ended fatally. 
Direct infection through the umbilical vessels is a frequent cause of pyaemia, 
and this same can result in haemorrhage. 

Etiology. — Hitter 2 studied 190 cases. Of these, 24 were associated with 
sepsis. Kilham and Mercelis 3 describe haemorrhages in 10 cases out of 54. 
It seemed that these were all due to one and the same pyogenic infection. 

Gaertner 4 describes a short bacillus which he isolated from two cases 
resembling the colon bacillus. When the same was injected into the perito- 
neum of animals, a disease was produced accompanied by haemorrhage 

*Read article on "Haemorrhages in Congenital Obliteration of the Bile-duct," 
page 35. 

2 Oest. Jahrbuch fiir Pediatrik, 1871,. p. 127. 
3 Archives of Pediatrics, March, 1899. 
4 Archiv fur Kinderheilkunde, 1895. 

(39) 



40 HEMORRHAGIC DISEASES OF THE NEW-BORN. 

similar to that seen in the new-born. Holt describes a case in which 
cultures were taken by Dr. J. J. Mapes from which a bacillus resembling 
that described by Gaertner was isolated. The absence of a sufficient quan- 
tity of calcium in the blood was supposed to be the prime cause of haemor- 
rhage. This has been disproven by the recent work of Addis. 1 Sahli and 
more recently Morawitz and Lossen have shown that the disease hemo- 
philia may be due to deficiency of thrombokinase. 

Pathology. — Small or large extravasations of blood may be found upon 
the various internal organs affected. The brain, the thymus gland, the 
stomach, the bowels, the pericardium, the pleura, and peritoneum may have 
ecchymoses upon their surfaces. A frequent source of haemorrhage is the 
presence of ulcers. Gastric and intestinal ulcers are by no means rare. 

Symptoms. — The first symptom noticed is the presence of blood. This 
may be present in the vomit, in the stool, or in the urine. There may be 
an oozing beneath the skin or from the umbilicus. The bleeding does not 
amount to a very large quantity. The infant is usually very anaemic. The 
pulse is small and feeble. The body is emaciated. The temperature fluc- 
tuates ; as a rule, it is subnormal, although it may be very high. The course 
of the disease is short ; the bleeding usually ceases in a few days. 

Umbilical Hemorrhage. 

Improper tying of the ligature around the umbilical cord or trau- 
matism frequently causes a slight oozing. These oozings are very easily 
controlled by the application of a proper-fitting ligature. When, however, 
a spontaneous haemorrhage occurs it may be impossible to arrest the same 
with ordinary means. In these cases the haemorrhage occurs without pre- 
vious warning. As a rule, the umbilicus has been perfectly normal for a 
few days prior to this haemorrhage. Some authors state that it may be 
fatal in less than twenty-four hours. 

Hemoglobinuria Neonatorum (Winckel's Disease). 

Considerable has been written upon this obscure condition, which is very 
rarely met with in the new-born baby. As a rule, this condition is seen as 
an epidemic in a maternity hospital. Winckel reports 19 deaths out of 
23 cases. 

Pathology. — Haemorrhages are found in various organs. The lungs are 
black. The bladder, the spinal canal, the liver, and the spleen all show 
darkened secretions. The kidneys are dark colored. All observers state 
that the umbilical vessels are not involved. 

Symptoms. — The skin of the body has a peculiar icteric or bronzed 
appearance. The palms of the hands and soles of the feet have a bluish 



1 Quarterly Jour, of Medicine, Jan., 1909. 



GASTROINTESTINAL HEMORRHAGE. 41 

or purplish color. The conjunctiva has an icteric appearance. The stool 
is blackish or greenish. The urine is dark and contains blood; it is thick 
and sometimes resembles syrup. There is no fever. The pulse is very rapid. 
Convulsions and squinting are usually seen. There is a rapid diminution in 
the blood cells, from 5,700,000 one day to 3,400,000 on the third day. 
These cases end fatally, as a rule. 

Acute Fatty Degeneration of the New-born (Buhl's Disease). 

When an infant is born in an asphyxiated condition and there is asso- 
ciated umbilical haemorrhage, then an infection of pathogenic bacteria may 
take place. In some respects this disease resembles WinckePs disease. In 
both we have haemorrhages as well as fatty degeneration of the internal 
organs. The symptoms are a bleeding from the stomach and bowels, asso- 
ciated with jaundice. In Buhl's disease we have bleeding from the um- 
bilicus. 

Gastro-intestinal Haemorrhage (Mel^na). 

Dark-colored, tarry stools are the usual symptoms of melaena. The 
black stool may also contain clots of blood. A crucial test for the presence 
of blood in examining the faeces for the presence of blood-corpuscles is the 
microscope. Normally, meconium does not contain blood. Another symp- 
tom is the vomiting of dark-brown liquids; occasionally bright-red blood 
may be present. 

Haemorrhages of the mouth and nose are generally due to syphilis, 
although ulcerative conditions may cause local haemorrhage. When pem- 
phigus or furunculosis is present, haemorrhages frequently occur. Haemor- 
rhage from the female genital organs may occur as well as from any other 
part of the body. They are usually associated with catarrhal inflammation 
of those parts. 

Diagnosis. — This is usually very easy, especially if the bleeding is 
superficial. The diagnosis is difficult when an obscure place like the intes- 
tine is the source of the haemorrhage. The microscope will usually aid in 
establishing a diagnosis of blood in the excreta. When the bleeding is 
confined to the mouth and nose, syphilis should be suspected. 

Prognosis. — A careful prognosis should always be given, although the 
disease is not necessarily fatal. Townsend studied 709 cases and recorded 
a mortality of 79 per cent. 

A male infant, six days old, was seen by me through the courtesy of Dr. A. 
Goldwater. The child had vomited several times. The vomit contained blood of a 
bright- scarlet color. The stool had been yellowish, but now is black and tarry. 
There was a slight oozing of blood from the umbilicus. When I applied some 
absorbent cotton to the umbilical stump, bright-scarlet blood was seen. The 
infant was well nourished and was nursed by its mother. The diagnosis of melsena 
neonatorum was made by the attending physician and I agreed in the diagnosis. 



42 HEMORRHAGIC DISEASES OF THE NEW-BORN. 

The treatment consisted in the application of a solid stick of nitrate of silver 
to the umbilicus, and strict aseptic dressing. The haemorrhages were probably due 
to pyogenic infection. 

Treatment. — Umbilical haemorrhage can best be controlled, as above 
cited, by the application of a solid stick of nitrate of silver followed by a 
dusting powder, such as: — 

I£ Aristol, 

Alum usta . .' aa 3ij, or 8.0 

Sig. : Dust over umbilicus. 

Thromboplastin has been recently used by me to control intestinal 
haemorrhage. Twenty cubic centimeters of this liquid should be diluted 
with 8 ounces of water. Excellent results were* obtained in a child seven 
years old who received, by mouth, a tablespoonf ul of this dilution, every 
half-hour. Twelve doses in all were given. This preparations can be pro- 
cured from the Kesearch Laboratory of the New York City Health 
Department. 

For the control of intestinal haemorrhage astringent injections are 
not to be relied upon. The suprarenal extract is a very good haemostatic. 
I have frequently used very small doses of hydrastine hydrochlorate, 1 / 50 
to Vioo grain, three times a day, or *4 to % grain suprarenal extract, 
repeated every hour. 

The injection of 15 cubic centimeters to 30. cubic centimeters of 
sterile horse serum is an excellent haemostatic. In the case of a "bleeder" 
recently seen by me in the Babies' Wards of the Sydenham Hospital, one 
injection of horse serum controlled the haemorrhage, due to a paracentesis, 
after all local means failed. 

If bleeding continues in spite of the injection of horse serum, an injec- 
tion of 15 to 30 cubic centimeters of human blood serum may be tried. If 
the latter fails we should resort to transfusion. Transfusion has been 
recommended by Lambert in haemorrhage of the new-born. 



CHAPTER V. 

INJURIES OF THE NEW-BORN. 

Fractures. 

Traumatism during labor is the cause of most fractures in the new- 
born baby. A predisposition may exist, due to defective ossification. When 
the skeleton is not properly developed, then a separation of the epiphyses of 
the long bones rather than an actual solution of continuity of the diapheses 
occurs (Ballantyne). 

This author also doubts the osteomalacic nature of fractures. Ante- 
natal fragility seems to exist by direct heredity. Griffith reports seventeen 
fractures occurring in one case 1 during the first two years of an infant's 
life. Thus we can see that there must be some other factor at work per- 
mitting recurring fractures, rather than invariably traumatism. 

It is true that syphilis has frequently been givem as a possible cause 
for a weak-boned skeleton. 

Brittle bones have been attributed to rickets. Prenatal disease on the 
part of the infant or its mother is frequently the cause of fracture. Linck 2 
describes a case of an infant that was born in little more than one pain. 
In this case there was found over thirty fractures in the limbs and ribs. 

Most of the fractures seen are of the "green-stick" variety. The prog- 
nosis in these cases is usually good, unless some complication appears. 

The following case was seen by me in consultation with Dr, A, S. 
Bienenstock, of New York: — 

An infant two days old had a fracture of the humerus. The seat of the 
fracture was in the center of the bone, and not near the epiphysis. 

Mother's History. — The mother of the infant suffered with diabetes for the 
previous eight years, having between 4 and 4.5 per cent, of sugar. During the 
latter months of pregnancy she was in a subnormal condition. The labor was 
dry, and quite some skill was required to deliver the infant. The mother had no 
breast-milk, so artificial feeding was resorted to. 

As this was in midsummer the infant soon became dyspeptic and later 
developed entero-colitis. At the seat of the fracture callus could be felt several 
days after I first saw this infant. Death resulted from summer complaint. 

Obstetrical Paralysis (Erb's Paralysis or Birth Palsy). 

This condition may be seen soon after birth, or it may not be noticed 
for several days after that event. It is a peripheral paralysis and usually 

1 American Journal of the Medical Sciences, Chap. CXIIL p. 426, 1897. 

2 Arch, of Gynaek., xxx, 264, 1887. 

(43) 



44 INJURIES OF THE NEW-BORN. 

involves the deltoid, biceps, brachialis anticus, supraspinatus, infraspinatus, 
and supinator longus muscles. It may also involve the extensor muscles of 
the wrist. 

Symptoms. — The arm hangs limp at the side of the body. The position 
is governed by gravitation. The forearm is extended and pronated, and the 
wrist and ringers flexed. Movement does not cause pain. The reaction of 
degeneration can be demonstrated when the paralyzed muscles are exam- 
ined with the electric current. Such examinations are very difficult in in- 
fants having a thick layer of fat. At times very powerful currents are 
necessary, thus provoking pain. In making an electrical test, the normal 
arm should always be compared with the affected arm. 

Erb demonstrated the fact that "it is possible by a careful examina- 
tion to find a spot two centimeters above the clavicle, back of the outer edge 
of the sternomastoid muscle, corresponding to the point of emergence of 
the sixth cervical nerve between the scaleni, at which point irritation by 
the faradic current will produce a contraction in the deltoid, biceps, 
brachialis anticus, and supinator longus muscles; and if the irritation be 
increased, the extensors of the wrist will also contract. Pressure upon this 
particular region is often made during delivery, either by the clavicle, or 
by forceps, or by the fingers of the obstetrician. This is more common 
when there is a breech presentation and the after-coming head is extracted 
in the common method. The index and middle fingers of the left hand 
being open like a fork over the shoulders of the child, traction is commonly 
made upon the shoulders, and the pressure of the obstetrician's finger in the 
neck often produces injury of the plexus. In some cases ' injury of the 
plexus is produced by attempts to bring down the hand or arm in breech 
presentations, or to replace these when the head presents. Forceps appli- 
cations in an awkward position may also produce this injury." 

Prognosis. — This depends on the time when the treatment is com- 
menced. As a. rule paralysis of the upper-arm type remains three or four 
years. In a case of mine seen recently the paralysis remained until the 
child was 5 years old. When the faradic current is applied and the muscles 
respond, then the prognosis is good; if there is no response, a cautious 
prognosis should be given. 

Treatment. — The arm should be supported with a sling. Massage aided 
by a faradic current is sometimes beneficial. In severe cases it is better to 
use the galvanic current, using the mildest current that will produce con- 
traction of the muscles. If the child is old enough to be instructed, gym- 
nastics should be tried at home daily. Strychnine may be given three times 
a day. 



CHAPTER VI. 

ASPHYXIA NEONATORUM (APPARENT DEATH OF THE NEW-BORN). 

The center and regulator of the respiratory movements is located in 
the medulla oblongata. From it also is sent the motor impulse which gives 
rise to the first act of respiration. 

The activity of this center is believed to be augmented by the condition 
of the venosity of the blood; therefore, all interruptions to placental respira- 
tion — for instance the premature detachment of that organ or the com- 
pression of the cord — and all obstacles to the introduction of air into the 
trachea, such as mucus or blood, will be attended witli violent motor im- 
pulses: first, efforts to breathe, and later, convulsive movements producing 
death (Boisliniere). 

There are two forms of this condition usually observed: first, the 
apoplectic form called by older writers livida, and second, the anaemic form 
called by older writers pallida. In the apoplectic form there is a bluish 
discoloration of the skin, a prominence and injection of the conjunctiva 1 , 
and a swollen state of the face and lips. The cardiac pulsations are gener- 
ally strong, and the cord is distended with blood. In the anaemic form the 
child has a deadly pallor; the lips and fingers are pale, the body limp, and 
muscles relaxed. The heart's action is inaudible, presenting the condition 
known as asystole. Duvergie, in studying the asphyxia of adults, noted that 
when people were removed shortly after an embankment of earth had buried 
them, they presented a turgescerice of the face, a violent hue of the skin, and 
frequent and regular pulsations of the heart. 

When they were found some time after an embankment of earth had 
buried them, they presented a deathly pallor of the skin, and the heart sounds 
were usually inaudible or very feeble. Thus it is apparent that the above 
conditions of asphyxia present, first, a mild; and then a severe type. 

Causes. 

The main causes of asphyxia are due to : — 

1. Compression of the cord in a natural way. 

2. Premature detachment of the placenta. 

3. Forced rotation of the head in difficult forceps application or great 
contraction of the uterus in head-last cases, thus rendering the vessels of 
the uterus impermeable to blood and suspending the placental respiration. 
Another cause of asphyxia is shortness of the cord from its encircling the 
neck tightly after the head is born. The child's face in this condition bo- 

(45) 



46 DISEASES OF THE NEW-BORN. 

comes turgid and blue, and unless relieved the child will die. The promptest 
treatment consists in cutting the cord above the child's head and delivering 
the infant's body as quickly as possible. Boisliniere advises the above 
method even at the risk of fracturing a humerus. 

Sign for Distinguishing the Stillborn from the Dead. 

Bedford Brown says that the best means for distinguishing the still- 
born from the dead is to be found in the temperature. If the temperature 
keeps near the normal, we must not cease our efforts at resuscitation, even 
if the complete suspension of cardiac and respiratory action has lasted for 
twenty minutes or more; but if the temperature of the child suddenly falls 
10, 15, or 20 degrees helow the normal, then the case is hopeless. Another 
sign is the state of the pupil : in the dead the pupil is widely dilated, in the 
stillborn it is but little, if at all, relaxed (Therap. Gaz., Vol. XXXI, 
Xo. 6). The method consists in injecting into each arm 5 drops of whisky 
with 1 drop of tincture of belladonna. If the infant is only stillborn, 
the nervous and circulatory system respond quickly. If there is no response 
or only a very feeble one, warm sterilized water is injected under the skin 
(a drachm or two) and also about 2 drachms with a drop of aromatic 
spirits of ammonia, into the intestines. After this dry heat is applied. If 
these measures fail to produce a reaction, it is a fair test of the absence of 
vitality. 

Treatment. — If the child presents a livid condition and is apparently 
apoplectic with the cord pulsating strongly, then cut the cord as soon as 
possible and allow at least an ounce of blood to escape. Sometimes it is 
necessary to cut the cord in several places. If bleeding does not ensue rap- 
idly, then the cord should be severed and placed in warm water at a tem- 
perature of 105° to 110° F. This will usually stimulate the flow of blood. 

When the child is born in a pallid condition and feels cold, then the 
cord should not he cut until all pulsations therein have ceased. It is in this 
condition that it will be so important to rapidly cleanse the mouth, nose, 
and larynx of mucus and blood. Some authors advise mouth-to-mouth suc- 
tion or suction made through a soft-rubber catheter placed, in the larynx, 
but these are usually preliminary means, and success will only follow me- 
thodical application of artificial respiration. 

Byrd's method is very simple. It can be conducted without rough 
handling, a matter of vital importance. The child's body rests on its back 
and is supported on the palm surfaces of the physician's hands. The physi- 
cian, by elevating and lowering his hands, can produce inspiration and 
expiration in a rapid and efficient manner. This method is well worth 
trying. An important point to remember is to pull the tongue forward; 
for this purpose an artery clamp will serve in an emergency, if the physician 
does not have Laborde's forceps for traction on the tongue. 



PLATE III 




The Byrd-Dew Method of Artificial Respiration. A, Extension. B, Semi- 
flexion. C, Complete flexion. (Grandin & Jarman. ) 



ASPHYXIA NEONATORUM. 



47 



Labor de advises rhythmical traction upon the tongue eight or ten times 
a minute. This is a valuable method and can be used while the child is 
immersed in hot water. Thus, the benefit of the stimulus on the tongue will 
be apparent while the hot bath is used. 

Hypodermics of strychnine, Vioo g ram ; combined with 5 or 10 
minims of whisky, may be indicated. Flushing the colon with a pint or 
more of water, temperature 110° or 115° F., to which a half-drachm of 
alcohol has been added, may also aid in stimulating the circulatory and the 
respiratory tract. It is advisable to persevere for some time with the 
above method of resuscitation, even though we may be successful. It fre- 
quently happens that new-born infants will respond to active treatment and 
show signs of life, but we must continue for some time, or the respirations 
will cease and the infant may die. 




Fig. 15. — Ribemont's Tube for Inflating the Lungs. 

A valuable means of restoring suspended animation consists in im- 
mersing the new-born infant, first, into very warm water, and then into cold 
water. Alternate from hot to cold water every ten or fifteen seconds. 



Inflation of the Lungs. 

This method is sometimes useful when other means fail. Some authors 
advise the mouth-to-mouth method. This consists in filling the cheeks with 
fresh air and then blowing the same into the infant's mouth. It can also 
be done by introducing a catheter into the infant's larynx. While the mouth- 
to-mouth method is simpler, it is not always a sure way of inflating the 
lungs. Quite frequently the air will be blown from the mouth, through the 
pharynx, into the stomach. To avoid the latter, the head should be thrown 
backward, and compression made over the epigastrium. If the nose is closed, 
air is less likely to enter the stomach. 

Mouth-to-mouth insufflation of air is not devoid of danger. Eeich 
reported a case of tuberculous meningitis due to attempts at reanimation 
by a tuberculous midwife. The Eibemont laryngeal tube is much safer. 



48 



DISEASES OF THE NEW-BORN. 



Eibemont's tube for inflating the lungs is inserted like an intubation 
tube. It serves two purposes : — 

1. Forcing air into the lungs. 

2. The aspiration of mucus from the trachea or bronchi. 

Great care should be used with any and all methods. No force is 
necessary. 




Fig. 16. — Infant Pulmotor. 



Literature records many successful cases of resuscitation of the asphyxi- 
ated child with the aid of the Draeger pulmotor. 1 

The infant pulmotor weighs twenty pounds and is carried in a box 
about 19 inches by 10 by 5. It contains a cylinder of oxygen. Each cylin- 
der contains oxygen sufficient for the continuous working of the apparatus 
for one hour (Fig. 16). 

Two flexible metal tubes connect the instrument with the mask: one 



X H. D. Fry, Surgery, Gynecology, and Obstetrics, Oct., 1913. 



ASPHYXIA NEONATORUM. 49 

forces the oxygen into the lungs under the required pressure ; the other is for 
suction, and removes the vitiated air from the organ. 

Technique. — The mouth, throat, and upper air passages are freed of 
mucus by gauze wrapped round the finger and by holding the infant head 
downward. It is then placed in the dorsal position upon a table or hard 
surface, shoulders raised and head extended. If relaxed, the lower jaw must 
be held up and pushed forward. The tongue is pulled well out with a silk 
thread passed through the tip. This is preferable to the forceps or tenacu- 
lum, as it does not interfere with the close application of the mask. The 
mask is tightly applied to the face, covering the mouth and nose, and held 
firmly by an assistant or by a rubber band encircling the head. The trachea 
is pressed gently against the spine so as to close the oesophagus, and if this 
is not enough to prevent distention of the stomach a small gauze sponge, 
attached to a string, can be placed in the oesophagus below the larynx. 
Inspiratory and expiratory movements are induced by moving the lever 
alternately from side to side, filling the lungs and expanding the chest 
walls, holding the inflation for a few moments, and then deflating the lungs. 
If the infant should make any voluntary effort to breathe, the manipulation 
of the apparatus should be so timed as to inflate during the inspiratory 
efforts and deflate during the expiratory. Efforts to resuscitate the infant 
should not be abandoned as long as there is any heart action. 



CHAPTER VII. 
FGETAL ICHTHYOSIS. 

This condition is described by Ballantyne, Kyber, Wassmuth, and 
Carbone as a skin disease of the foetus most probably developed about the 
fourth month of intrauterine life. It consists of horny epidermic plates 
over the whole surface of the body, separated from each other by fissures 
and furrows, associated with certain deformities of the mouth, nose, eyes, 
ears, and extremities, and leading to the death of the infant very soon after 
birth. 

It is a rare condition, as only 42 cases could be found in the whole 
literature up to the year 1895. For the following case I am indebted to 
Dr. A. S. Daniel:— 

Clinical History. — This case was first seen five hours after birth. The child 
had passed urine and meconium, cried continuously, sleep was impossible. The 
slightest jar of the crib or exposure to the air increased the crying. The respiration 
was irregular, the surface of the body cold. The child swallowed with difficulty 
and was fed with the aid of a medicine dropper. The child died suddenly twenty- 
four hours after birth. The temperature taken soon after birth was 103° F. 

Description of the Child. — There was no resemblance between the child and a 
human being or any living thing. The tongue was the only part of the body that 
seemed capable of motion. The body presents the appearance of having been in an 
integument much too small for the skeleton, and Nature in its growth had so 
stretched the skin that it has the appearance of being torn in some places. Where 
it is torn through, a purple-covered slit appears; where torn partly through, a 
yellowish-colored fissure remains. There is no uniformity of arrangement of the 
fissures. Fewer are found on the back, and those on the extremities are more 
shallow. The color of the fissure, a purplish red, is in marked contrast to the color 
of the skin. In a few places bright blood is found, as if the break were of recent 
origin. The whole body is cold and rigid. The scalp is divided into fissures and 
numerous irregular conical projections, varying in size. A few thin hairs are 
found on the lateral surface of the scalp. The external ears are replaced by conical 
projections. The palpebral fissures are filled with purplish-red masses; deep down 
in the sockets, eyeballs can be distinguished. The nose is flattened and is identified 
by the widely opened nostrils. The mouth is open, showing a non-hypertrophied 
tongue. The lips are of a purplish-red color. The mouth measures 5 centimeters 
in length. Circumference of head, 36.5 centimeters; glabella to occiput, 18.5 
centimeters; ear to ear, 15.5 centimeters. The neck is short. Anteriorly a 
fissure extends from the neck to the umbilicus, 2 centimeters in width. From this 
fissure, ridges of yellow skin and purple fissures extend toward the axillae; they 
are of irregular size and depth. 

The extremities are rigid and in the foetal position. The arms can be raised 
only at right angles with the body. They cannot be extended at the elbow. The 

(50) 



FCETAL ICHTHYOSIS. 51 

hands are thickened and the fingers are rudimentary. The legs are crossed. The 
motion at the hip and knee joint is very imperfect. The toes are rudimentary. 

The median raphe in the scrotum is faintly marked; testicles are not 
descended. The penis is x /-> centimeter in length. The anus is open. The length 
of > the foetus is 42 centimeters, and its weight is 4 pounds 13 ounces. In this case 
it was impossible to find any clinical cause for the disease. 

Of the cause of foetal ichthyosis practically nothing is known. That 
it is not a fatal disease in utero is demonstrated by the fact that only one 
case thus far has been stillborn. 



CHAPTER VIII. 
INFLAMMATORY AND NON-INFLAMMATORY CONDITIONS. 

Icterus Neonatorum. 

This form of icterus is frequently designated as a physiological con- 
dition. It usually begins on the second or third day after birth, and may 
continue for a week or even a month. Henoch reports a case of icterus 
brought to his clinic which lasted five weeks and ended fatally. The ma- 
jority of text-books describe this condition as a mild disease and give a good 
prognosis. There are many theories as to the causes leading up to this 
condition. The hematogenic theory maintains that a disintegration of red 
corpuscles takes place. This liberates the haemoglobin, giving rise to the 
yellowish pigmentation. 

Kacchi, of Naples, disproved the correctness of this theory by a series 
of blood-counts which he reported at the International Medical Congress 
held at Rome in 1895. 

"We can scarcely believe that the red corpuscles simply go to pieces in 
the blood, and that the products of such disintegration, floating freely about 
or temporarily lodged in the tissues, give rise to the yellow color. It is far 
more in accordance with the workings of the living organism to suppose 
that the disintegration takes place in some organ, e.g., liver or spleen, and 
if the products thereof are floating about, it is after passing such organ 
and on their way to final elimination." 

Infant F. J. was seen by me when three days old. Had greenish stools con- 
taining mucus, and appeared colicky and cried considerably. No vomiting. There 
was a universal yellowish pigment of the body; jaundice well marked; gums were 
yellowish; conjunctival mucous membrane showed yellowish pigmentation. The 
umbilicus was somewhat excoriated and moist from the presence of pus. The 
diagnosis made was septic omphalitis, resulting in haematogenic jaundice. Very 
small doses of calomel, y 10 grain, several times a day, were ordered; also colon 
irrigations with chamomile tea. The infant was nursed by its mother. Aseptic 
treatment of the umbilicus with sterile gauze, cleansing with bichloride, and then 
dusting the parts with talcum salicylicum quickly healed the inflammatory con- 
dition. The infant recovered in about one week, showing no sign of its previous 
jaundice. 

The following case is noteworthy owing to its rarity : — - 

An infant was born of apparently healthy parents. Dr. Mehrenlander, the 
physician in attendance, stated that there was nothing abnormal at the time of 
birth. The infant weighed about seven pounds. It was the fourth child. Three 
children of this same family had previously died on the third day after birth. They 

(52) 



SCLEREMA NEONATORUM. 53 

were to all appearances healthy, but were jaundiced. Nothing was noticeable with 
them, excepting the yellow pigmentation of the skin. The child died before I ar- 
rived at the bedside. It was three days old. The skin then presented a deep yellow- 
ish-green pigmentation, more marked on the abdomen. The conjunctival mucous 
membrane was deeply pigmented. There was no inflammatory condition noticeable 
in the region of the umbilicus. The cord was dressed with . aseptic gauze, and no 
infection was suspected from this channel. The attending physician suspected 
syphilis in the father. There were no other symptoms. Neither vomiting nor 
diarrhoea. A. stool passed before the infant died, which looked like meconium. 

An interesting point about the case is that this was the fourth child in that 
family which died of icterus neonatorum a few days after birth. The child died 
without any apparent suffering, showing no symptoms of illness. The temperature 
when taken was normal. 

Zweifel describes a series of cases of icterus resulting from the effects 
of chloroform passing through the placenta. The writer has noted the asso- 
ciation of icterus neonatorum in a large number of children born after a 
severe labor, requiring prolonged chloroform narcosis. This may have been 
accidental, yet it is worth noting. 

James D. Voorhees, in responding to my question concerning the asso- 
ciation of chloroform anaesthesia and icterus at the Sloane Maternity Hos- 
pital, states that "all women receive chloroform at said hospital, and about 
33 per cent, of the infants born are jaundiced. All premature infants 
also are jaundiced." 

Sclerema Neonatorum. 

This disease is characterized by a hardening or thickening of the skin 
and the subcutaneous cellular tissue. The pathological lesions have been 
carefully studied by JSTorthrup. His case was a foundling born amid insani- 
tary surroundings. -When five days old the legs were swollen and the feet 
as hard as a board. 

The swelling spread upward, involving every part of the body. The 
temperature in the rectum was 35° C. (95° F.). The infant died on the 
ninth day. The body felt as though it were frozen. Osier also describes 
this condition in this country. 

Symptoms. — An oedema-like swelling, very cold to the touch, and very 
hard on palpation, involving circumscribed areas, appears soon after birth. 
I have seen sclerema spread from the shoulders to the trunk and arms. 

The infant appears very sick. The temperature is subnormal, and 
recovery is rare. 

Was called to see an infant five days old. Found the trunk swollen, the hands 
and feet cold, and the temperature in rectum subnormal. The infant refused the 
breast and had no strength. Brandy and water were prescribed. Mustard foot-bath 
ordered, and one pint of warm saline solution injected into the colon. There was no 
nausea or vomiting. No retention of urine. Sclerema neonatorum was diagnosed. 
The swelling spread, involving the legs and arms, until the whole body, including the 



54 INFLAMMATORY AND NON-INFLAMMATORY CONDITIONS. 

face, was puffed and hard. The infant could no longer open its eyes and died on 
the ninth day in convulsions. 

Mastitis Neonatorum. 

The new-born infant frequently secretes a fluid in the mammse. Fe- 
males, both human and animal, occasionally secrete milk without having 
been previously pregnant. With regard to the milk secreted by infants, 
there is some doubt about its real nature. Kollicker does not view it as a 
true milk, but considers its appearance connected with the formation of 
the mammary glands. This secretion is also known as witch's milk. 

Sinety, on the other hand, upon anatomical grounds, considers it a 
true lacteal secretion. It probably is a sort of imperfect milk, loaded with 
leucocytes, and this is the more likely as Vollard 1 notices that it frequently 
ends in abscess. 

Schlossberger gives an imperfect quantitative analysis of a sample of 
milk obtained by squeezing the breasts of a new-born infant, a male. In 
the course of a few days about a drachm was obtained. The following was 
the result of the analysis : — 

Water 96.75 

Fat . . 0.82 

Ash 0.05 

Casein, sugar, and extractives 2.83 

Sugar-reaction , strong 

The most complete analysis we possess of such milk is by von Gesner : — 

Milk-fat 1.456 

Casein 0.557 

Albumin ■ 0.490 

Milk-sugar 0.956 

Ash 0.826 

Water 95.705 

Total solids 4.295 

I was called to see a female infant six days old. The mother told me that the 
breasts were swollen and contained milk. The same could be expressed by gentle 
stroking of the mammae. The treatment consisted of the application of an ice-bag 
and inunctions of: — 

Ifc Ung. ext. belladonna 2 drachms 

Ung. hydrarg. cin 1 drachm 

Cold cream 1 ounce 

M. Apply on linen with tight compresses. 

After several days the breast dried and the swelling disappeared. 
Another infant, three weeks old, was seen by me recently, in consultation. The 
mother was delivered by a midwife, and her condition as well as that of the infant 

1 "Traits des Maladies des Enfants Nouveau-nes," third edition, 1837, p. 717. 



PERITONITIS IN THE NEW-BORN. 55 

was apparently normal. The infant's breasts, when seven days old, appeared tender 
and swollen, and the mother was advised to poultice them with flaxseed. This she 
did, and in addition squeezed the secretion from the inf unit's oreasts. This trauma- 
tism caused irritation, inflammation, and finally the formation of an abscess. An 
incision was made, the pus evacuated, and the wound healed. 

It is important to remember that the lacteal secretion in an infant's 
breast is a physiological condition, and if undisturbed will be absorbed 
gradually. 

Erysipelas in the New-born. 

When this disease occurs in the new-born, and the mother has a septic 
peritonitis or other infectious disease, the infant should be immediately 
isolated from the mother. The symptoms are the same as those seen in 
erysipelas of older children, although vomiting and symptoms of general 
sepsis most often accompany this condition. The fontanel is depressed. 

Prognosis. — The prognosis is usually very grave, especially so if the 
infant must be removed from its mother's breast. 

Treatment. — The strictest antisepsis must be used. An infant should 
be placed under the care of a trained nurse, and all instructions in regard 
to the trygiene of the infant must be strictly carried out. The general plan 
of treatment is the same as that outlined in the chapter on "Erysipelas." 

Tuberculosis in the New-born. 

The transmission of tuberculosis from the mother to the new-born 
is extremely rare. Cases are on record in which the tubercle bacilli were 
transmitted from the mother to the infant. An occasional transmission of 
tuberculosis takes place through the placenta. The reason for the infre- 
quency of this occurrence is that the blood of a tuberculous patient rarely 
contains tubercle bacilli. Schmorl and Birch-Hirschfeld believe that ma- 
ternal tuberculosis can be transmitted, but not before the end of the fifth 
month of pregnancy, and that the placenta is always tuberculous when the 
foetus is infected. (For further details see chapter on "Tuberculosis.") 

Peritonitis in the New-born. 

Under "Septic Omphalitis" I have described a case of septic infec- 
tion seen in consultation practice. The case recovered. At times the in- 
flammatory condition will extend from the umbilicus to the peritoneum, and 
thus a septic peritonitis results. 

Bacteriology. — In such pyogenic infections the streptococcus can be 
found. The bacteria gain entrance directly through the umbilical vessels. 

Pathology. — The same lesions affecting the serous membrane, as the 
pleura and the pericardium, are found in the peritoneum, idhesions fre- 
quently remain. 



56 INFLAMMATORY AND NON-INFLAMMATORY CONDITIONS. 

• The symptoms, prognosis, and treatment are described in the article 
on "Acute Peritonitis," Part V. 

Pemphigus Neonatorum. 1 

This condition is seen occasionally in the new-born infant. It consists 
of blebs, which contain yellow serum. In size they vary from that of 'a pea 
to that of a small bean. When these rupture they are replaced by superficial 
ulcers covered with a thin, black crust. Sometimes a violet stain is left, 
which may last for some time. The duration of each bulla is about one week. 
The location of the eruption is on the palms of the hands and the soles of 
the feet. It is a streptococcus infection. The cases seen by me have in- 
variably occurred in poorly nourished children such as we find in athrepsia 
(marasmus). 



1 See article on "Chronic Pemphigus." 



CHAPTER IX. 
ABNORMALITIES AND CONGENITAL MALFORMATIONS. 

Angeioma. 

Circumscribed dilatations of the blood-vessels or capillaries are occa- 
sionally seen in the new-born baby. ' Spongy tumors consisting of tortuous 
blood-vessels of a bluish-red color are usually seen. These tumors are filled 




Fig. 17. — Infant ten months old. From my children's service at the 
German Poliklinik. The mass of bluish, tortuous vessels interfered with 
the eyesight. Bleeding was very easily provoked. Surgical treatment was 
the only means of eradicating this mass. (Original.) 

with blood and grow very rapidly. In a case seen by me (see Fig. 17) the 
mass was adherent to the forehead and completely obliterated the sight of 
the left eye. This condition is one that can easily be remedied by prompt 
surgical treatment. Some cases will, if neglected, ultimately result in 
sarcomatous degeneration. 

Treatment. — Injections into the mass of a 5 per cent, nitrate of silver 
solution, or destroying the mass with a galvanocautery, chromic acid, or 

(57) 



58 ABNORMALITIES AND CONGENITAL MALFORMATIONS. 

nitric acid, are most generally used. A good plan is to apply first pure 
carbolic acid, after which the fuming nitric acid should be used. This 
latter method is painless and effective. 

Harelip. 

This congenital deformity is frequently seen in children. Sometimes 
it is simply "a slight indentation in the lip, or the fissure may extend to 
the nostril." The treatment is surgical. 




Fig. 18. — Harelip Nipple. 1 



Cleft Palate. 



This abnormality is frequently seen in children. While the soft palate 
only may be affected, it not infrequently happens that the fissure extends 
through. the hard palate, thus causing a wide gap in the roof of the mouth. 

Feeding Children with Cleft Palate. — An infant born with cleft palate 
has a greater struggle for existence than a child born without this deformity. 
It is advisable to give the best possible food, and, therefore, breast-milk only 
should be used. The milk should be drawn from a woman's breast by 
means of a breast-pump, as described in the section on "Specimen of Breast- 
milk for Chemical Examination." 

An artificial nipple should be attached to the feeding-bottle, and to the 
former should be attached a flap of India rubber so made that it fits the 
roof of the mouth. The pressure of the nipple against the piece of rubber, 
when in position, converts it into an artificial palate-piece, and prevents 
the escape of the milk into the nose during the effort of swallowing. This 
shield is chosen to avoid permitting curdled milk to pass into the recesses 
of the turbinated bones and to cause aphthous patches. (See Fig. 18.) 

It is advisable to operate on an infant for this deformity between the 
third and sixth months of its life, if sufficient progress in its development 
will warrant it. 

When the above method of feeding is not satisfactory and the child 
shows evidences of starvation, then we must resort to gavage. ( See article 
on "Gavage.") 

Our aim should be to build up the infant from its birth, with breast- 
milk if obtainable. In one case known to me the breast-milk was pumped 



1 This harelip nipple can be procured from the Miller Rubber Manufacturing Co., 
Akron, Ohio. 



CONGENITAL ADENOIDS. 59 

off every four hours and the infant was nourished by gavage with this milk. 
When breast-milk is not obtainable, then properly modified milk should be 
used, to conform with the age and requirements of the child. If the child 
does not assimilate its food properly a the operation should be postponed until 
the child is built up and strong enough to stand the operation; hence the 
guide for estimating the time for the operation is dependent more on proper 
feeding than on any other factor. 

Hygienic measures are very important, as the irritation by food will 
frequently cause inflammation in the mouth. For details of the surgical 
treatment the reader is referred to the many good text-books on operative 
surgery. 

Tongue-tie (Adh.esia Linguje). 

Tongue-tie consists of an abnormally short frsenum. In some instances 
it may interfere with nursing, and possibly with speaking. It is one of the 
most trivial disorders of infancy. 

Treatment. — Incise the frsenum near its attachment to the tongue with 
a pair of curved scissors. The incision may be enlarged with the aid of 
some dull instrument. Some authors advise using the finger-nail, which 
latter, however, is not aseptic. A tongue-tie should not be operated upon 
if an infection exists in the immediate surroundings. 

The after-treatment consists in using a bland mouth wash, such as a 
1 per cent, listerine solution, or 1 per cent, alum solution, especially after 
feeding the child. 

Congenital Adenoids. 

We occasionally meet with infants in which this condition exists. This 
mechanical impediment prevents breathing through the nose. An infant, 
therefore, is at a great disadvantage, because it cannot breathe while nurs- 
ing. The following case will serve to illustrate this condition : — 

I was called to see an infant, Mary W., in consultation. The attending physi- 
cian gave me the following history: The infant is twenty days old and weighs 6 
pounds and 14 ounces. At birth she weighed 7 pounds. She was nursed at the 
mother's breast for about one week. The infant seemed to dislike the breast, as she 
would draw and immediately let go of the nipple. The mother believed the infant did 
not like the taste of her milk. A wet-nurse was procured, and the same trouble was 
encountered; the infant would take one swallow and then let go of the nipple in 
order to get her breath. A nipple-shield was then used, but the same difficulty was 
encountered. The family believed that the infant did not like breast-milk, so she 
was given bottle feeding. She took the nipple of the bottle, drew quite well, and 
then let go, when it was necessary for respiration. I ordered spoon feeding, and this 
worked quite well. The breast-milk was pumped from the wet-nurse and fed by 
spoon. This method was successful. The child swallowed a spoonful of milk and 
then had a chance to breathe. An examination of the rhino-pharynx revealed 
adenoids. These were removed with the aid of a sharp spoon, and three days later 
normal conditions existed. 



60 ABNORMALITIES AND CONGENITAL MALFORMATIONS. 

The infant was again put to the breast when six weeks old and continued to 
nurse successfully for six months. She was then weaned, owing to the illness of 
the wet-nurse. Cows' milk was substituted. The child is today a perfectly healthy 
little girl. 

Protrusion of the Ears. 

Protrusion of the ears is frequently seen in children. The anxious 
mother will consult the physician regarding the treatment. These cases are 
easily managed in very young infants. A fenestrated cap. closely fitting to 
the head so that the ears are well held back in their normal position, has 
served me very well. Young infants object to having their heads covered, 
but soon become accustomed to this cap, as it is only worn at night and 
removed in the morning. It is advisable to change the cap frequently, as 
some children perspire from its use. It must be worn for months before any 
benefit is noted. 

In very severe cases in which the above treatment is not successful, it 
may be necessary to call in the surgeon. The operation is a simple one and 
the result is excellent. 

Abnormalities of the Air Passages. 

When there is deficient oxygenation of the lungs, collapse frequently 
occurs, and is called atelectasis pulmonum. This condition is due to the 
unaerated condition of the vesicles. The trouble is usually found in the 
nasopharynx in the form of adenoids, unless some rare malignant condition 
is present. 

Many pigeon-breasted children — with apparent rachitic manifestations 
of the thorax — owe this anatomical peculiarity more to improper oxygena- 
tion of the lungs than to improper feeding. In such children it is not rare 
to meet with congenital adenoids. (Read article on "Congenital Ade- 
noids.") 

It is to be understood that changing the food or giving restorative treat- 
ment, such as iron or codliver-oil, cannot cure such a child until the cause 
is eradicated. 

Congenital Stenosis of the Larynx. 

In the chapter on "Inherited Syphilis" I describe a case of syphilitic 
stenosis of the larynx which necessitated a tracheotomy. Several years ago 
a child was brought to my clinic suffering with cyanosis and difficult breath- 
ing. Intubation was tried without affording any relief. As a last resort 
tracheotomy was performed, but this afforded no relief. A post-mortem 
examination showed that we were dealing with a diverticulum of the trachea. 
In addition thereto the larynx and trachea were lined with a series of syph- 
ilitic ulcerations. 



CEPHALHEMATOMA. 61 



Prominent Sternum. 

This is frequently called pigeon-breast. It is usually seen in older 
children. It is occasionally seen as a result of Pott's disease, but more fre- 
quently it is associated with rickets. It has been described by me in the 
chapter on "Bachitis." 

Depressed Sternum. 

Congenital depression of the sternum is occasionally seen in very young 
infants. It is more frequently seen as a funnel-shaped depression, and is a 
symptom of structural weakness. It more often accompanies a general 
rachitic manifestation, to which I call attention in the chapter on "Rachitis." 



HEMATOMA OF THE STERNO-MASTOID. 

During labor traumatic conditions frequently induce haemorrhages. 
These conditions are, therefore, seen in natural labor with very large chil- 
dren, or when forceps are used. Pressure is cited by most authors as one of 
the causes of this condition. Henoch believes that hsematoma of the sterno- 
mastoid is caused by twisting the head during labor. The swelling is due 
to an extravasation of blood and to inflammatory conditions of the muscle. 
It is rarely seen before the child is two or three weeks old. There is no 
treatment necessary. The blood is absorbed and the swelling gradually 
disappears. 

Cephalhematoma. 

A swelling is sometimes seen on the top of the head during the first 
few days of the infant's life. It is usually associated with the application 
of forceps or a similar injury during labor. This condition is rare in chil- 
dren, The statistics of the Sloane Maternity Hospital show that this con- 
dition was met with in 20 out of 1300 consecutive births, or 1.6 per cent. 
There may be several swellings. They are most frequently seen over the 
parietal or occipital bone. 

Symptoms. — A swelling that is very soft and fluctuating is noticed. 
This swelling gradually increases in size, and attains its maximum at the 
end of twelve or fourteen days. There is no pulsation palpable. The tem- 
perature is usually normal. 

Diagnosis. — This condition is frequently mistaken for encephalocele. 
The latter, however, is always seen in conjunction with the fontanel or along 
the line of the sutures. 

Pressure causes cerebral symptoms. This condition can be confounded 
with hydrocephalus. In the latter the symmetrical enlargement of the whole 
head is alwavs a characteristic feature. 



62 ABNORMALITIES AND CONGENITAL MALFORMATIONS. 

Baby M., seven days old, was born with the aid of forceps, after a very diffi- 
cult and dry labor. When the infant was three days old a swelling was noticed on 
the scalp over the left parietal bone. This swelling gradually increased in size and 
felt soft, doughy, and fluctuating. An incision was made which liberated about four 
ounces of clear, fluid blood. Several days later this case was also seen by Dr. Willy 
Meyer, and as suppuration existed it was necessary to treat the wound on general 
surgical principles. The child recovered. 

Treatment. — The above case illustrates the mistake that can be made. 
A hematoma is a benign condition and disappears without treatment. 
Bandaging and compression are unnecessary, but injury to the part must 
be avoided. 

Caput Succedaneum (Spurious Cephalhematoma: 
Supplementary Head). 

This is a swelling of the scalp due to congestion, resulting in an ex- 
travasation of the blood and lymph into the subcutaneous tissue which is 
external to the pericranium. This swelling does not fluctuate. It is usually 
seen in that portion of the head which first presents itself at the vulva dur- 
ing labor. No treatment is required, as this condition usually becomes 
normal. 

Congenital Cyst oe the Kidney. 

The literature records an occasional case of this condition. There are 
no symptoms which would be the means of determining this condition dur- 
ing life. The diagnosis is therefore made post-mortem. 




Fig. 19. — Congenital Cystic Kidney, half natural size. ( Langerhans. ) 

Congenital Sacral Tumor. 

J. B., male infant, eleven months old, was brought, to my children's service 
at the German Poliklinik. He was breast-fed and appeared in good health. The 
mother noticed a large swelling over the sacral and lumbar regions. The infant did 



CONGENITAL MALFORMATIONS OF THE RECTUM. 63 

not seem to be in pain. The growth was non-inflammatory and did not interfere 
with the movements of the legs. The diagnosis of congenital lipoma was made and 
an operation advised. The case was sent by me to Dr. Geo. F. Shrady for operation 
at St. Francis Hospital. The tumor was removed. The case recovered. 




Fig. 20. — Congenital Sacral Tumor. (Original.) 

Congenital Malformations of the Eectum. 

E. E. Kirby 1 states that these occur under the following types : — 

1. Congenital narrowing of the anus or rectum, without complete 
occlusion. The anal aperture is at times preternaturally small, either in 
consequence of a contraction of the lower end of the rectum, or from the 
fact that the skin may extend occasionally over the border of the anal mar- 
gin. The diagnosis is usually easy, for the contraction is near the anus and 
Can be readily detected by the finger, or seen when due to a fold of skin 
extending across the anus. The treatment consists in dividing the ring or 
skin on the dorsum, and daily dilatation, either with the finger or soft-rubber 
bougie. 

2. Closure of the anus by a membranous diaphragm (atresia of the 
anus) is the simplest of all forms of congenital malformations, and is treated 
by a crucial incision through the membrane. 

3. In imperforate rectum one may expect to find some of the most diffi- 
cult cases of malformation, although some are comparatively simple. In- 
stead of a normal anus the skin of the perineum extends across the anal 
region from side to side, and the rectum may terminate quite a distance 
from the normal site of the anus. The intervening space may be made up 
of connective tissue, while a circular elevation or depression marks the nor- 
mal site of the anus. Occasionally a distinct fibrous cord may be traced 

1 "Congenital Rectal Malformations." Archives of Pediatries, August, 1897. 



64 ABNORMALITIES AND CONGENITAL MALFORMATIONS. 

from the rectal pouch to the skin. If the rectal pouch be not at too great 
a distance from the skin, a sense of fluctuation may be felt by firm pressure 
of one finger over the anus and the hand over the abdomen. 

4. The system which separates the anal and rectal pouches in cases of 
imperforate rectum with a normal anus is generally within easy reach of the 
anus. It may be perforated and slow dribbling of meconium allowed. There 
may also be more than one septum. 

5. The anus may be absent and the rectum open at any point in the 
perineum or sacral region. The lower portion of the rectum in these cases 
is usually of a fistulous character, lined by true mucous membrane, and the 
abnormal anus is always narrow and insufficient for its purpose. Occasion- 
ally the rectum terminates in two distinct openings, at a greater or less 
distance from each other. 

6. The anus may be absent and the rectum terminate in the bladder, 
urethra, or vagina. In females the vaginal opening is the most common; 
in males the vesical. This condition is usually rapidly fatal unless relieved 
by prompt surgical interference. 

7. The rectum or the large intestine may be entirely absent. 
Kirby lays down the following rules : — 

1. An operation should always be performed, and performed without 
delay. 

2. If there be any chance of establishing an opening at the normal site 
of the anus, the surgeon should at first direct his attention to this procedure. 

3. The use of a trocar as an aid in finding the rectal pouch before or 
after incision through the perineum is not sanctioned by modern surgical 
authority. 

4. The results of attempts to establish an outlet for the imperforate 
rectum through the perineum are not favorable as regards the production 
of a useful anus. 

5. In case of failure to establish a new anus in the anal region, colotomy 
should at once be performed. 

6. In the formation of an artificial anus the left groin is the best site 
for the operation. 

7. Attempts at establishing an anus in the anal region after a colotomy 
are attended with great danger, and are generally unsuccessful. 



PART III, 

NUTRITION. 



CHAPTER I. 
THE INFANTILE STOMACH. 

The infantile stomach is vertical and cylindrical and the fundus but 
little developed. Thus, whenever there is a tendency to vomit, the anti- 
peristaltic motions do not press against the fundus, but directly upward. 
There is, therefore, rather an overflow than a vomiting of the gastric con- 
tents; this takes place so easily that the infants are not disturbed by it. 1 

Anatomy. — The muscular development is weakest at the fundus. Ac- 
cording to Meischmann, the oblique and the longitudinal fibers described 
by Henle, which have their origin at the pyloric opening, "do not exist in 
the infant." The investigations of Leo and von Puteren show that, in spite 
of this lack of muscular development, the stomach of a nursing infant is 
emptied in one and a half or two hours. With food that is more difficult 
to digest, the gastric contents are propelled more slowly. 

The Mucous Membrane of the Stomach. — The mucous glands are far 
more numerous on the pars pylorica than in adults, whereas they are far 
fewer in number at the cardia. 

The mucous membrane of the infant secretes gastric juice, which, in 
general, is similar in properties to that of the adults. The amount of. secre- 
tion in the infant is far less than in the adult, while its chemical constitu- 
tion is the same, namely: pepsin, lab-ferment, and acids. The exact pro- 
portion of the ferment and pepsin has not yet been studied sufficiently to 
admit of any positive deductions being made. 

Physiology. — It is very important to know that the mucous membrane 
of the mouth is practically dry at birth; the secretion of saliva is very 
small, and, according to Korowin and Zweifel, increases toward the end of 
the second month. 

The fermentative (sugar-forming) property of saliva, which is trifling 
at the commencement, increases with the quantity of the saliva secreted. 
This is essentially true of other secretions; thus, the pancreatic juice does 
not have the same emulsifying properties in the infant as in adults. 

The nursing or sucking center is located, according to experiments 
made on animals by Basch, in the medulla oblongata on the inner side of 
the corpus restiforme. 

The sucking act is reflex; according to Auerbach, the muscles of the 
tongue participate most actively. 



Jacobi, "Therapeutics of Infancy and Childhood," page 25. 

5 (65) 



66 



NUTRITION. 



Acids in the Infant's Stomach. — The gastric contents in a nursling 
contain two acids: (1) hydrochloric acid; (2) lactic acid. The relative 
acidity is smaller than in adults, the highest point being reached one and 
a half hours after nursing. According to von Puteren, the acidity is two 
and one-half to three times as small as in the stomach of adults. Accord- 
ing to Leo, the acidity of the gastric juice of nurslings iy 2 hours after 
drinking is only 0.13 per cent., whereas, in the adult, after the same time, 
the acidity is from 1.5 to 3.2 per cent. According to Wohlmann, free HC1 
can be found in healthy nurslings from l 1 /^ to 2 hours after taking food. 
The percentage of free HC1 ranges from 0.83 to 1.8 per cent. 

Lactic Acid. — The quantity of lactic acid is, according to Heubner, 
between 0.1 and 0.4 per cent. 

Pepsin and Hydrochloric Acid. — There are two chief functions of the 
pepsin and hydrochloric acid which are the same in both infant and adult : 
First, the power of killing bacteria : a real bactericidal power. Second, as 
a solvent for albumin. Thus, it is apparent that pathogenic micro-organ- 
isms that might have entered the stomach can be destroyed, although we 
know the small quantity of acid is hardly able to cope with large quantities 
of food contaminated with bacteria. 

Unorganized Ferments. — The unorganized ferments seem to be nitrog- 
enous bodies; their exact composition is unknown, and it is doubtful if 
they have ever been obtained perfectly pure (Landois and Stirling). 

Action of the Saliva on Various Bacteria. — Triolo describes a series 
of interesting experiments with saliva. He first irrigated the mouth with 
bichloride or permanganate of potash solution, followed this by irrigation 
with sterilized water until the disinfecting substances were removed, and 
then inoculated the surface of various culture-media with the sputum. His 
results proved that saliva possesses a distinct bactericidal property, for 
cultures of five-day-old bacteria were destroyed, as well as fresh bacteria 
eighteen hours old. 

This property, however, was lost when saliva was filtered. The saliva 
of. the parotid and submaxillary glands, taken singly, were equally effica- 
cious as their combined secretion. He believes that the greatest bactericidal 
action is due to the secretion of the mucous glands in the mouth. 

The Influence of Gastric Juice on Pathogenic Germs. — Gastric juice is, 
according to the experiments of Drs. Kurlow and Wagner, an exceedingly 
strong germicidal agent, and when living bacilli get into the intestinal 
canal it is due to various conditions entirely independent of the gastric 
juice. When the latter is normal and in full activity, only the most prolific 
microbes — such as tubercle bacilli, the bacilli of anthrax, and perhaps the 
staphylococci — escape its destructive action; all others are destroyed in less 
than half an hour. Similar influences exist in the intestines, as proved by 
inoculation with the cholera bacilli. 



THE INFANTILE STOMACH. 



67 



Table No. 8. — Showing the Unorganized Ferments Present in the Body 
and Their Actions. 



Fluid or Tissues. 


Ferment. 


Actions. 






Converts starch chiefly into mal- 
tose. 










Converts proteids into peptones in 
an acid medium, certain by- 
products being formed. 

Curdles casein of milk. 

Splits up milk sugar into lactic 
acid. 

Splits up fats into glycerine and 
fatty acids. 


Gastric juice . . 


2. Milk-curdling 

3. Lactic-acid ferment. . . . 

4. Fat splitting 




1. Diastasic, or amylopsin . . 

2. Trypsin 


Converts starch chiefly into mal- 
tose. 

Changes proteid into peptones in 
an alkaline medium, certain 
by-products being formed. 

Emulsifies fat. 

Splits fat into glycerine and fatty 
acids. 

Curdles casein of milk. 


Pancreatic juice . 


3. Emulsive (?) 

4. Fat-splitting or steapsin . . 

5. Milk-curdling . 




1. Diastasic 


Does not form maltose, but mal- 


Intestinal juice . 


2. Proteolytic 

3. Invertin 


tose is changed into glucose. 

Fibrin into peptone (?). 

Changes cane-sugar into grape- 
sugar. 

In small intestine (?). 




4. Milk-curdling 


Blood 

Chyle .... 
Liver (?) .... 

Milk 

Most tissues . . . 


Diastasic ferments .... 




Muscle ..... 
Urine 


Pepsin and other ferments . 




Blood ..... 


Fibrin-forming ferment . . 





Judging from the results of experiments made by Zagari, Straus, and 
Wurtz, who exposed various pathogenic organisms, ■ among others that of 
tuberculosis, to the action of gastric juice, we must come to the conclusion 
that, so long as the gastric juice retains a sufficient degree of acidity, tuber- 
culosis of the alimentary canal will be unlikely to occur. 

Albumin and the Gastric Juice. — Another property of gastric juice in 
infants is the transformation of albumin in the following manner: (1) 



68 NUTRITION. 

albumose; (2) then peptone, (3) and lastly syntonin. It is thus appar- 
ent that, although the infantile stomach plays a subordinate role as a nour- 
ishing organ, it cannot be denied that fluid substances — like water, a solu- 
tion of salt, and solution of sugar — are absorbed, and in a less degree albu- 
min also. The relative size and capacity of the stomach prevent the func- 
tion' from being as thoroughly developed as in the adult. 

Stomach Capacity. 

At birth the infant's stomach has a capacity of from 9 to 11 drachms, 
or 35 to 43 cubic centimeters. At the end of one month it is about 2 ounces, 
or 60 cubic centimeters. 

At the end of three months the gastric capacity is about four times 
the. amount at birth. The very rapid increase from birth to this time soon 
ceases, and the stomach capacity grows in size, but at a much slower rate 
of development (Baginsky). 

The series of experiments at the Children's Hospital of St. Petersburg, 
made by Ssnitkin, showed that the weight, and not the age, determined the 
capacity of the stomach, and should be used as a guide for the quantity of 
infant-food required. 

If the normal (initial) weight of an infant is 3000 to 4000 grams, or 
about G.G to 8.8 pounds, then 1 / 100 part, plus the daily increase in weight 
added, which normally amounts to from 2 / 3 to 1 ounce, would give the 
amount of food required. 

Biedert also regards the body weight as an important factor in deter- 
mining the amount of milk to be given. Baginsky argues that, while this 
rule will hold good for a great many infants, he must insist upon relying 
upon the scales to show just how much nutriment has been digested, and 
thus a regular system of weighing, plus the inspection of the stools, will 
aid in establishing the quantity of food necessary. "There is no unanimity 
among experienced clinical observers upon the subject of infant-feeding." 
The majority of clinicians the world over order cows' milk in varying 
dilutions. Some use the cereals — like wheat, barley, rice, and farina — to 
dilute and subdivide the curd. Other clinical observers — Budin and Variot, 
French observers — advise giving infants, at birth, whole milk; that is, pure, 
undiluted coivs' milk. 

The following illustrations will serve to show the difference in the 
capacity of infants' stomachs at various ages, taken by the author at the 
morgue of Bellevue Hospital. 




Fig. 21 —Infant's Stomach, Actual Size. From a Case of Malnutrition. Capacity, 
About 2 Ounces. When Stomach was Filled it Held 4 Ounces Easily. (Author's Col- 
lection.) 




Fig. 22.— Infant's Stomach. Actual Size. Died Suddenly from Convulsions. Age 
Seven Months. Cause of Death, Eclampsia. Capacity when Filled with Water, 8% 
Ounces. (Drawn from Specimen in Author's Collection.) 



(69) 




Fig. 23. — Infant's Stomach. Capacity, 10 Ounces. Age of Child, Eleven 
Months. Cause of Deaih, Enteritis. (Drawn from Specimen in Author's Col- 
lection.) 



/r- 



v 




Fig. 24.— Capacity of Measurement, 14 Ounces. Diseased Condition. Normal Capacity. 
Holding About 2 Ounces, or 50 Cubic Centimeters. (Author's Collection.) 



(70) 



SIGNIFICANCE OF VOMITING. 71 

Significance of Vomiting. 

The symptom of vomiting needs careful interpretation. When the 
symptom occurs in gastric and intestinal conditions it is not difficult to 
make a diagnosis. It is important to note the frequency of vomiting : Does 
or does it not occur after every feeding ? Has the infant had a stool during 
the last twelve hours? Intestinal obstruction is usually accompanied by 
frequent vomiting and the absence of stool. Intestinal worms are frequently 
a cause of vomiting. Likewise, an early symptom of appendicitis is vomit- 
ing. Feeding high percentages of fat may provoke vomiting; likewise, ex- 
cessive quantities of sugar may produce vomiting as well as colic from 
flatulence. Pyloric spasm and pyloric stenosis are usually accompanied by 
vomiting. 

Vomiting is a reflex act. It can be produced directly by irritating 
the stomach, as, for example, when mustard is swallowed. It can also be 
produced by a great many vegetable products, as, for example, by ipecac 
root. Mineral poisons, such as sulphate of zinc or turpeth mineral, or sul- 
phate of copper, will produce violent emesis. Bacterial fermentation from 
stagnant food can also produce vomiting. These causes are, therefore, direct 
in their action and produce immediate results. It is a great mistake to 
look upon the stomach or the stomach contents as the etiological factor in 
vomiting, and as the only organ capable of producing emesis. 

The toxins in the blood of many acute infectious diseases produce vom- 
iting. One of the earliest symptoms of scarlet fever is vomiting. Several 
days before the eruption of scarlet fever appears, vomiting of a most violent 
nature generally occurs. This is, no doubt, due to toxaemia. 

An irritation of the vagus or the pneumogastric nerves can result in 
vomiting. Any irritation brought about through the central nervous sys- 
tem will cause vomiting; thus it is that shock, fright, or disturbance of 
metabolism may produce vomiting of a most serious nature. 

Giddiness, caused by swinging or a rolling motion, as on a ship, may 
produce cerebral hyperamiia, ending in vomiting. When a child falls on 
the back of its head and produces concussion of the brain, we have con- 
tinued vomiting as a first symptom. When vomiting persists in spite of 
gastric treatment, meningeal disease should be suspected. In meningitis, 
especially in hydrocephalus, vomiting is a frequent symptom. The writer 
does not presume that any physician will diagnose brain fever, scarlet fever, 
or gastric fever by the single symptom of vomiting. 

On the other hand, it is well to know that vomiting, with a suspicious 
rash and a sore throat, will strengthen the suspicion of an existing scarlet 
fever. A rule followed by the writer is to lay considerable stress on vom- 
iting. It means nothing if we are dealing with a spoiled stomach following 
a large dish of plum pudding. But woe to the physician who gives a good 



72 NUTRITION. 

prognosis where vomiting is an early manifestation of intracranial disease 
that ends fatally. 

Stomach Washing. 

When vomiting persists, especially in pyloric spasm, stomach washing 
(lavage) is indicated. One teaspoonful of bicarbonate of soda added to one 
pint of warm water can gradually be introduced by pouring through a fun- 
nel attached to a soft-rubber or flexible catheter. While many clinicians 
advise placing the child in an upright position during the lavage, I have 
found, especially in younger infants, that it is easier to fill the stomach 
and syphon off the gastric contents while the child is flat on its back. In 
the dorsal position the tube can be gently but quickly forced over the tongue, 
down the pharynx, through the oesophagus, into the stomach. In washing 
the stomach the funnel, holding three or four ounces, should be filled, and 
raised above the level of the stomach. After the fluid has entered -the 
stomach, we can syphon off the contents by lowering the funnel below the 
level of the stomach. This process should be repeated several times or until 
the return flow from the stomach is clear. 

It is advisable to wash the stomach, preferably before food has been 
given. In obstinate vomiting lavage should be performed daily. No force 
should be used in pushing the tube into the stomach. The eyelet of the 
catheter should be carefully inspected to see that there are no sharp edges. 
An injury to the gastric mucosa by laceration with a sharp border of a 
stomach-tube will certainly result in an erosion. 

The Abdomen". 

The abdomen of a child is comparatively larger than that of the adult. 
Especial attention should be given to the condition of the abdomen; for 
instance, a retracted abdomen is usually seen in meningitis. (See chapter 
on "Meningitis.") A distended abdomen is frequently seen in rachitis 
(pot-belly). (See article on "Rachitis.") A very prominent abdomen is 
seen in chronic peritonitis, to which I direct attention in the special article 
dealing with that subject. 

The Intestines. 

Small Intestine. — At birth the length of the small intestine is nine and 
one-half feet. The length of the intestine may, however, vary with the size 
of the child. In the duodenum Brunner's glands are found. Below the 
duodenum Peyer's patches are found. The most important physiological 
function of the small intestine consists in aiding the assimilation of food 



THE INTESTINES. . 73 

by the action of the pancreatic juice and other secretions. The emulsifica- 
tion of the fat in the food takes place in the small intestine. 

Length of the Intestine. — The relative length of the intestine in nur- 
slings is greater than in adults, so that the intestines are six times as long as 
the body. Forster believes this is one reason why nurslings receive more 
nourishment from milk than do adults. The small intestine develops during 
the first two months of life more than the large intestine, and after the 
second month the reverse is true. The duodenum remains relatively the 
longer until the end of the fourth month. The transverse colon is the widest 
and most elastic portion of the large intestine. The continuation of the 
large intestine in infants, into the rectum, is indicated by a narrowing at 
this point. 

Large Intestine. — According to Treves, the large intestine measures : — 

At birth 1 foot 10 inches, or 55 centimeters 

At 12 months 2 feet 6 inches, or 76 centimeters 

At G years 3 feet, or 91.5 centimeters 

At 13 years 3 feet G inches, or 107 centimeters 

Course of the Colon. — From the right iliac fossa up to the liver, then 
transversely across the abdomen to the spleen and then downward, ter- 
minating in the rectum. The colon forms at its first turn the hepatic 
flexure, at the spleen the splenic flexure, and finally the sigmoid flexure. 
The curve of the sigmoid flexure occurs in the left iliac fossa. 

Sigmoid Flexure. — The anatomical illustrations of the sigmoid flexure 
(see article on "Chronic Constipation") are important to remember in 
view of the mechanical cause of constipation so frequently seen in young 
children. 

The transverse colon, when distended with gas, is very easily mapped 
out by percussion. 

The Caecum. — D wight found the caecum completely covered with peri- 
toneum in 33 out of 37 cases in young children. Treves states that in 100 
cases observed by him he found the peritoneum infolding the caecum in 
all of these cases on its posterior surface. 

The caecum occupies a higher position anatomically in a child than 
in adult life. 

Vermiform Appendix. — [Behind the caecum lies the vermiform appendix. 
It is important to remember that it lies in the line midway between the 
umbilicus and the crest of the ilium. When the appendix is inflamed and 
swollen it can frequently be mapped out by rectoabdominal (bimanual) 
palpation. 



74 NUTRITION. 

Formation of Gas in the Intestine. — When we consider the lesser 
development of the muscles of the intestine, we can readily understand 
that peristaltic movements are more irregular and less forcible, and that 
the muscles possess less tone; on this account there is a larger amount of 
gas contained in the intestine, which constantly distends it. Thus it is 
apparent why the abdomen always appears larger in the infant in propor- 
tion to the other parts of the body. 

Action of Intestinal Muscles. — The action of the intestinal muscles is 
chiefly to transport the food by a series of peristaltic movements. Parts 
of- the intestine are active, while others remain passive. Heubner maintains 
that post-mortem examinations never show all parts of the intestine in the 
same condition, owing to the irregularity of the muscular movements. 

Development of Glandular System. — The development of the glandular 
system in infants is very poor, whereas the lymphoid tissues and follicles 
are comparatively well developed. 

Lieberkuhn's glands are fewer in number than in adults, whereas the 
©■runner glands in the duodenum are numerous and well developed. 

The Secretory and Absorbing Power of the Epithelium and the Glands. 
— Heubner maintains that the secretion takes place from cells, located in 
the small intestine, which are scattered about and are few in number, 
whereas in the large intestine they are far more numerous. 

Absorption of Fat. — The absorption of fat takes place through the 
intestinal epithelium in the duodenum and jejunum; the glands also par- 
ticipate in this action. According to the histological investigations by 
Baginsky, the real absorbing system of the intestinal wall is found in the 
connective-tissue bodies of the mucous membrane of the infantile intestine, 
in which are located lymphatic vessels connected with the larger lymph- 
channels of the intestine. The physiological and chemical functions are 
much less developed in infants than in adults, because the intestinal glands 
are relatively less developed. 

BREAST-MILK AND WET-NURSING. 

Colostrum. 

Colostrum is found in the breast of a woman several hours after giving 
birth to her infant. It resembles milk, but is a much thinner fluid. It is 
always the forerunner of a healthy normal secretion of breast-milk, which 
usually appears on the third day after the birth of the infant. 

Colostrum corpuscles have been described by Czerny as lymphoid cells, 
whose function is to absorb and reconstruct unused milk globules and to 
convey them from the milk-glands into the lymph- channels. These cor- 
puscles usually disappear in one week or ten days after birth. When colos- 



BREAST-MILK. 75 

trum corpuscles are present after one month, then such milk will cause 
gastric disturbances. It is a wise plan to examine the milk microscopically 
whenever the slightest evidence of gastric or intestinal disturbance is noted. 

According to Baginsky, colostrum contains large quantities of serum- 
albumin, and is also very rich in fat and colostrum corpuscles, and contains 
a large quantity of salts. The last two ingredients are supposed to be the 
cause of the laxative action of the colostrum. 

When colostrum corpuscles persist in breast-milk, in spite of the regu- 
lated diet and the hygienic condition of the mother, then breast-feeding 
must be discontinued. A very fretful and nervous mother will frequently 
have colostrum corpuscles in her milk. An instance of this kind was seen 
recently by me. Substitute feeding will frequently modify this condition 







COLOSTRUM 
CORPUSCLES 



Fig. 25. — From a drop of milk on the third day after delivery. 
(Zeiss Ocular 4, dd Lens.) (Original.) 



unless there is a specific cause for the same. When a nursing mother is 
very weak and anaemic after her confinement, then iron is indicated. I saw 
a case in consultation recently in which the combined use of fresh air, 
cereals, and iron changed a thin milk containing colostrum corpuscles into 
a thick, creamy milk in less than one month. Continued menstruation or 
uterine disorder with disease in the endometrium may cause profound 
anaemia and thus render breast-milk very thin. Such milk is totally unfit 
for the proper nutrition of the infant. 

Breast-milk. 

According to Pfeiffer, human milk contains, several days after the 
birth of the infant, a large quantity of albumin, salt, and a small quantity 
of fat. He also found that the longer the period of nursing, the smaller the 
quantity of albumin, which, in the eleventh month, sinks quite low. There 



76 



NUTRITION. 



Table No. 9. 

Properties of Human Milk. 

Appearance. Bluish, semitransparent, no odor, sweetish. 

Specific Gravity. 1026 to 1036. 

Reaction. ' Amphoteric, relation of alkalinity and acidity as 3 to 1. 



On Boiling;. 



Coagulates. 



f Does not coagulate, and forms a very thin, hardly-per- 
l ceptible skin. 

At ordinary temperature after several hours. 



Coagulates on addi- r 

tion of T ab-fer- J Coagulates imperfectly in small isolated flakes, which 



ment. 



do not precipitate as a uniform coagulum. 



Fat. 



Yellowish white, resembling cow-butter. Specific gravity 
at 15° C, 0.966. Melts at 34° C. 



Varieties of Fat. 



Butyrin, palmitin, stearin, olein, niyristin, caproin. 



Behavior of Various f Few volatile acids. More than half of the non-volatile 
Acids. I consist of oleic acid. 



Difficult to precipitate with acids and salts. The pre- 
Milk-plasma Casein, -j cipitate redissolves in excess of acids. During pepsin 
digestion there is no pseudonuclein produced. 



f Lactalbumin and lactoglobin ; relation of casein to albu- 
Composition of Albu- j min, 0.5 to 1.2 or 1 to 2.4; of the 1.3 per cent, 
minoids. albumin, there are 64 parts of casein, and 37 parts 

of globulin and albumin. 



Solids. 



Less solids than in cows' milk, especially CaO — P 2 5 . 



ative Analy- r 

,. I Water, 87.41; 

according to 4 

, , ( 6.21; solids, 



Quantitative Analy 

sis 
Soxhlet. 



albuminoids, 2.29; fat, 3.78; milk-sugar, 
0.31. 



Bacteria. 



Usually sterile, rarely staphylococcus albus and aureus. 



PROPERTIES OF COWS' MILK. 



77 



Table No. 10. 
Properties of Cows' Milk. 



Appearance. 
Specific Gravity. 



( Opaque white or whitish yellow, in thin layers bluish 
C white, slight odor, faintly sweet. 

1028 to 1036. 



Reaction. 



{Amphoteric; relation between alkalinity and acidity, 
2 to 1 ; Soxhlet maintains that cows' milk contains 
three times the acidit}^ of human milk. 



On Boiling:. 



Does not coagulate and forms a skin containing casein 
and lime-salts. 



Coagulates. 



Coagulates very soon, owing to lactic-acid formation. 



Coagulates on addi- 
tion of Lab-fer- 
ment. 



{Coagulates to a solid mass at body-temperature, from 
which a yellowish fluid can be expressed. 



Fat. 



Yellowish-white mass. Sp. gr. at 15° C, 0.949 to 0.990. 



{Palmitin, olein, stearin, myristin, caprilin, caprin, 
caproin, butyrin, laurin, lecithin, cholesterin, and yel- 
low coloring matter. 



Behavior of Various 
Acids, 



Volatile fatty acids, about 70 per cent. ; not volatile, 
0.3 to 0.4 per cent, of oleic; the remainder consists of 
palmitic and stearic chiefly. 



Milk-plasma Casein. 



( Easy to precipitate with acids and salts; excess of acid 
1 does not dissolve; belongs to the nucleo-albumin group. 



Composition of Albu- 
minoids. 



Less lactalbumin and globin; the largest portion of the 
albuminoids is casein. Relation of casein to albumin, 
0.3 to 3.0, or 1 to 10. 



Solids. 



Cows' milk contains more solids than human milk. 



Quantitative Analy- 
sis, according to 
Soxhlet. 



Water, 87.17; albuminoids, 3.55; fat, 3.69; milk-sugar, 
4.88; solids, 0.71. 



Bacteria. 



Contains all milk bacteria, frequently also pathogenic 
bacteria, as typhoid, diphtheria, and tubercle ba- 
cilli, etc. 



78 



NUTRITION. 



is also a decrease in the quantity of salts, whereas the amount of sugar 
steadily increases. The fat varies constantly. According to Johannessen, 
the quantity of albumin in the first six months is 1.192 per cent. ; in the 
next six months 0.989 per cent., and at the end of the year 0.907 per cent. 

Breast-milk varies according to the length of time that it remains in 
the breast, and also the length of the nursing period; so it has been shown 
that the first milk taken at the beginning of the nursing act is the poorest 
in nutrient value, whereas the last milk is richest in fat. The longer the 
milk remains in the glands of the breast, the more will the solid substances 
of the same be absorbed, so that only a watery solution remains. If sucking 
is commenced, this stimulation soon changes the character of this watery 
milk, so that normal milk will soon be secreted. Forster studied the chem- 
ical constitution of the first, middle, and the last portions of milk from a 
nursing woman, with the following result. 

In one hundred parts he found : — 

Table No. 11. 



Water 

Nitrogenous Substances 

Fat 

Sugar 

Ash 



First Portion of the 
Nursing Act. 



90.24 
1.13 
1.70 
5.56 
0.46 



Second Portion Dur- 
ing Nursing. 



89.68 
0.94 

-2.77 
5.70 
0.32 



Third Portion at the 
End of the Nursing 
Act.. 



87.50 
0.71 
4.51 
5.10 

0.28 



The quantity examined was 37.3 grams. 

From a study of the foregoing tables we find a decrease of nitrogenous 
substances during the course of the nursing, a steady increase in the amount 
of fat, and an unvarying percentage of sugar. Thus, it is apparent that, in 
order to submit a specimen of breast-milk to a chemical examination, it is 
necessary to stimulate the secretory functions of the mammary glands by 
putting the child to the breast at least two minutes ; thus an even milk can 
be procured. If this rule is overlooked, then we shall find proportions in 
the chemical components of milk which might otherwise be entirely dif- 
ferent. The most recent chemical analysis of breast-milk shows that in a 
hundred parts there are : — 

Solids 11.5 

Liquids 88.5 

Of the solid constituents there are : — 

Casein 1.2 to 1.03 

Albumin 0.5 

Fat 0.8 to 4.07 

Milk-sugar 6.0 to 7.03 

Ash 0.2 to 0.21 



BREAST-MILK. 79 

The above is the chemical examination of a good average breast-milk; 
I again call attention to the fact, however, that not only does the milk vary 
in different women, but it also varies in the same woman during one single 
nursing act. 

The albuminoids of milk consist of real casein, lactalbumin, globulin, 
and opalisin. This latter body has only recently been discovered by A. 
Wroblewski, and more recently by Schlossmann. 

Phosphorus exists in milk as nuclein-phosphorus. Wittmaack has 
demonstrated the fact that the phosphorus in woman's milk exists as an 
organic nitrogen compound in the casein. 

According to the examination of Stolasa, lecithin contains a larger 
quantity of phosphorus in woman's milk than in cows' milk. 

The specific gravity of breast-milk varies from 1026 to 1036. 




Fig. 26. — Heeren's Pioscop, for Optical Milk Test. 

The Mammary Glands. — The mammary glands of the same woman 
may yield somewhat different milk, as shown by Sourdat and later by 
Brunner. Also the different portions of milk from the same milking may 
have different compositions. The first portions are always poorer in fat 
(Parmentier, Peligot, and others). 

According to l'Heritier Vernois and Becquerel, the milk of blondes 
contains less casein than that of brunettes : a difference which Tolmatscheff 
could not substantiate. Women of weak constitutions yield a milk richer in 
solids, especially in casein, than women with strong constitutions. 

According to Vernois and Becquerel, the age of the woman has an effect 
on the composition of the milk, so that we find a greater quantity of protein 
and fat in women 15 to 20 years old and a smaller quantity of sugar. The 
smallest quantity of protein and the greatest quantity of sugar are found 
at 20 or from 25 to 30 years of age. The milk with the first-born is richer 
in water — with a proportionate diminution of the quantity of casein, sugar, 
and fat — than after several deliveries. The influence of menstruation seems 
to slightly diminish the milk sugar and to considerably increase the fat and 
casein. 

Pioscop. — One drop of milk can be examined in the pioscop and com- 
pared with the colors on the same. This is a rapid but rough method of 
estimating the richness of the milk. 



80 



NUTRITION. 



Table No. 12. — Comparative Analyses of Breast-milk. 



Human Milk. 


Fat. 


Proteins. 


Sutrar. 


Ash. 


Authority. 


Normal Milks. 












Average 


2.90 
3.68 
2.67 
3.52 
2.53 


3.07 
1.70 
3.92 
2.01 
3.42 


5.87 
7.11 
4.37 
5.91 

4.82 


0.16 
0.20 
0.14 


A. W. Blythe. 

Marchand. 
Vernois & Becquerel. 
Hammarsten. 
Simon. 


Average 


Average 


Average 


14 analyses from same woman 


0.23 


Mean of 6, aged 23-33 years. 


3.82 


2.04 


5.93 


0.42 


H. Gerber. 


Average 


3 55 


1.52 
2.39 


6.50 
6.83 


0.45 
0.29 


Chevalier & Henry. 
J. Bell. 


From woman aged 18 


3.20 


From woman aged 33 


2.99 


2.51 


6.51 


0.30 


J. Bell. 


4 days after delivery 


4.30 


3.53 


4.11 


0.21 


Clemm. 


9 days after delivery 


3.53 


3.69 


4.30 


0.17 


Clemm. 


12 days after delivery 


3.34 


2.91 


3.15 


0.19 


Clemm. 


Average of 84 samples 


4.13 


2.00 


6.94 


0.20 


Leeds. 


Average of 107 samples.... 


3.78 


2.09 


6.21 


0.31 


Konig. 



Specimen of Breast-milk for Chemical Examination. — After the third, 
possibly the fourth, day the average healthy woman secretes milk that 
gradually becomes normal in quality and quantity, depending on her 
general condition. It is usual for an infant to lose some weight during 
its first week of life, owing to various physiological changes, added to 
which is, no doubt, the deficiency in the quality and quantity of its food. 
It is a safe plan, and one that I have always urged, if at all possible, 
to send a specimen of breast-milk to a chemist and submit the same to 
a chemical analysis. In some women a specimen can be examined when the 
baby is one week old; in others it is better to wait until the end of two 
weeks. We then would have a proper working basis, and know just how 
much fat, carbohydrate (sugar), and albuminoids — including protein — we 
are feeding. Noting the weight of the child, its sleep, its digestion, color 
and frequency of its stools, we can easily see in one week how much the 
infant has gained in weight, and its general condition. To take a specimen, 
it is advisable to have all utensils absolutely clean; hence the following plan 
would be suggested : Boil an ordinary one or two-ounce bottle in water, to 
which a pinch of baking soda has been added, for about one-half hour. 
Then place the bottle in plain water and boil again for a half -hour. Then 
turn the bottle upside down, and allow it to drain and dry. In this manner 
we can completely sterilize the inside of the bottle and avoid contamination. 

Withdraw a sample of breast-milk by means of a breast-pump. One 
which has served the author very well is known as the Florence breast-pump, 
and has a glass mouth-piece. (See Fig. 33.) Another form is an English 
breast-pump, having a rubber bulb. Compressing this bulb, we can suck 
about an ounce or more in from five to ten minutes. This milk is to be 
poured into the bottle, and well corked, and set in a refrigerator, but 



PLATE IV 




A Drop of Normal Breast-milk from a Primipara. (Original.) 



BREAST-MILK. 



81 



not on the ice. Milk will keep for many hours in this way. My plan has 
been to inform the chemist the day previous to submitting the sample, so 
that it can be withdrawn frojn the breast early in the morning — at about 
8 a.m. — and sent to the laboratory at once. The result of the analysis can 
be received on the evening of the same day or on the following day in all 
instances. A point worth noting is that the very first milk should not be 
used, but the infant should be allowed to suck at the breast for about two 
minutes before pumping the sample. After this the breast-pump should be 
applied for five minutes to procure the middle milk; then the infant can 
again be put to the breast to finish nursing. 




Fig. 27. — Specimen of Breast- 
milk from a Young Mother, 17 years 
old. Primipara. Baby four months 
old; thriving; gaining in weight; 
stools yellow; sleeps well. Chemical 
examination : Fat, 2.60; sugar, 6.50; 
proteins, 2.54. Milk looks creamy, 
and the mammae are well filled. 

(Original.) 




Fig. 28. — Specimen of Breast- 
milk, Illustrating Very High Fat, 
Causing Gastric Disturbance. Baby 
gaining; vomits frequently; stools 
yellowish; bluish-white milk; child 
sleeps well ; excessive fats. Chem- 
ical analysis: Fat, 5.0; sugar, 6.50; 
proteins, 1.74; ash, 0.20. (Original.) 



Examination of Breast-milk. — A method which can be employed in 
general practice is recommended by Friadmann (Deut. med. Wocli., Jan. 
23, 1902). It is more easily done than a chemical analysis, and serves 
an equal purpose. It consists of determining by microscopical examination 
the number and character of the milk corpuscles. It is an advantage first 
to become familiar with the normal conditions by repeated examinations 
of the milk from healthy mothers, those whose children are well and show 
no sign of rickets or glandular enlargements. The milk corpuscles can 
be divided as to size into three groups, large, small, and intermediate, of 
which the latter are most numerous. The small ones are also found in 
almost equal numbers, but the large ones are comparatively scarce, a mag- 
nification of 400 diameters showing only about 10-20 in the field. If these 



82 NUTRITION. 

be more numerous the milk is found to be too fatty and more difficult to 
digest. A preponderance of the small corpuscles usually means a chronic 
dyspepsia for the nursing infant. An accurate count can be made with 
some form of blood-counting apparatus, but the latter is not essential. The 
proximity of the corpuscles to each other also serves as a guide to the grade 
of the milk, the more sparsely distributed the globules and the greater the 
number of the small ones, the poorer the quality of the milk. The method 
also serves to differentiate the character of the milk from the two breasts. 
In the selection of wet-nurses it is obviously useful. 

Reaction of Human Milk. — Bordet has called attention to the precipi- 
tation of the albuminoids in milk when it is added to the serum in animals 
which have been previously injected with milk from the same source. 
Schlossmann found, further, that the fluid from a hydrocele on a breast 
child was also able to precipitate the albuminoids in human, but not in cows' 
milk. According to Moro, if a few drops of human milk are added to a 
few cubic centimeters of fluid from a hydrocele, in a very few minutes the 
hydrocele fluid coagulates into a solid mass. This reaction does not occur 
with cows' or goats' milk. The hydrocele fluid evidently contains fibrinogen, 
and "the milk, fibrin ferment. The combination of the two induces the 
coagulation. It occurs even with minute quantities of the milk; all the 
serum in contact with the milk coagulates around it. The same reaction 
occurs when human serum is added instead of the milk, but much less pro- 
nounced and much slower, and the same difference is observed when the 
human milk is boiled or long heated. Particles of coagulated ox blood also 
induced a slow and partial coagulation. 

It seems to be established that the mucous membrane of the stomach 
secretes an enzyme or fat-splitting ferment. Ibrahim discovered a lipolytic 
ferment in the stomach of a nursling. 

Diastatic Enzyme in Human Milk and in the Stools- of Nurslings. — 
Dr. Ernest Moro reports from Escherich's clinic, in Graz, that : — 

First. — Human milk contains, normally, an intensive, saccharifying 
enzyme, which is not found in cows' milk. 

Second. — This enzyme is found in the stool of breast-fed children and 
signifies a more pronounced diastatic action of the same. 

Third. — This diastatic enzyme is secreted by the glands of the intestine. 
Parts of the same can be found in the pancreatic juice of the new-born. 

Fourth. — The intestinal contents and faeces of nurslings contain at birth, 
as a rule, a diastatic enzyme, which increases in the first few weeks of life. 

Immunity Conferred by Breast-milk. — The nursing infant is usually 
exempt from infectious diseases, although we do find an occasional case of 
infection in a breast-fed infant. Such is the exception rather than the rule. 

Read chapter on "Measles" for cases of immunity seen by me in the 
Riverside Hospital. 



BREAST-MILK. 



83 



There seems to be an immunity combed to the infant through its 
mother's milk. These substances which convey immunity have been 
studied by Brieger and Ehrlich. During epidemics nursing infants rarely 
succumb to infections. The following case will illustrate the manner in 
which immunity can be "conveyed"" through the milk: — 

A woman suffering with diphtheria was four months pregnant at the time of 
infection. She was injected with 2000 units of antitoxin and recovered in about 
six da} T s. Several months after the birth of her child, an older child in the family 
Avns attacked with diphtheria, which required several injections of antitoxin, also 
intubation, to relieve a severe form of croup. Although the new-born infant was 
in the same room it did not show any signs of the disease. This was most likely due 
to the immunity conferred upon the child by its mother through her breast-milk. 

To Preserve Human Malk. — Human milk collected from various 
women may be preserved for many weeks if treated in the following 
manner: Test the milk with litmus paper to be sure that it is ampho- 
teric or alkaline. If it is not alkaline, add a few drops of bi-carbonate 
of soda solution. Then add 0.2 cubic centimeters of a concentrated 30 
per cent, perhydrol solution. This quantity of perhydrol is sufficient 
for 400 cubic centimeters milk. The milk is then thoroughly shaken so 
that the perhydrol produces its chemical effect. On close inspection 
small bubbles can be seen in the milk. Lastly the milk is heated for ten 
minutes in a water ''bath to 120 degrees F. Milk so treated by Dr. 
Meierhoffer was tasted by me in the Children's Wards of Dr. Paul Moser, 
in Vienna, and seemed perfectly fresh although it was one month old. 

Table No. 13.! — Five Analyses of Human Breast-milk. 1 





Case 

No. 1. 

Per cent. 


Case 

No. 2. 

Per cent. 


Case 

No 3. 

Per cent. 


Case 

No. 4. 

Per cent. 


Case 

No. 5. 

Per cent. 


Water 


86.2 
1.7 
6.5 
5.4 
0.2 


89.0 
1.3 
5.8 
2.5 
0.3 


87.0 
1.6 
6.6 
3.8 
0.2 


88.6 
1.1 
6.7 
2.7 


88 1 


Proteins 


1.1 


Lactose 

Fat 


6.2 
4.1 


Salts 









Case I of Table 13 showed symptoms of gastric disturbance, chiefly 
vomiting, caused by "feeding high fat/ 5 The mother of the infant believed 
that by eating frequently and of very rich food, she would benefit her baby, 
thus her milk showed 5.4 per cent, of fat. 

By reducing her diet, excluding meat and too many eggs, discontinuing 
alcoholic and malted beverages, her milk improved, the fat being decreased. 
Exercise, such as walking, was ordered for the mother. 



1 Analyses made by Lafayette B. Mendel, Yale University, New Haven, Connec- 



ticut. 



84 



NUTRITION. 



Table No. 14. — Table Showing Analyses of a Normal, a Poor, 
an Over-rich, and a Bad Human Breast-milk. x 





Normal Milk. 
Exercise and 
Good Food. 


Poor Milk. 

Poor Food. 

(Low Fat. 

High Protein.) 


Over-rich Milk. 

Rich Food. 

No Exercise. 

(Excess of Fat ) 


Bad Milk. 

Wet-nurse 
Menstruating. 

(Low Fat. 
Low Protein.) 


Fat 


4.00 

6.50 

1.75 

.19 


1.00 

6.50 

2.36 

.24 


6.59 

6.69 

1.16 

.19 


.65 


Sugar 


6.50 


Protein 

Mineral Matter . . . 


1.12 
.11 


Total Solids 

Water . . 


12.44 

87.56 


10.10 
89.90 


14.63 
85.37 


8.38 
91.62 






Total 


100.00 


100.00 


100.00 


100.00 



Specimens examined by Mr. Bailey, chemist of the Pediatrics Laboratory. 

Breast-feeding. 

During the first and second months feed every three hours, but never 
oftener. 

During the day awaken the child every three hours, to be nursed; but 
during the night let the child rest as long as it appears satisfied. This 
rule applies to healthy children only. In sickness special rules for feeding 
are required. If the child thrives and gains in weight, then it is advisable 
and in the interest of the mother and child to have an interval of from seven 
to eight hours at night; thus Bouchut advises the last feeding between 10 and 
11 p.m., and the first feeding at 6 a.m. If the child is restless, then turn 
it from side to side; thus, changing its position and giving it one or two tea- 
spoonfuls of boiled water will frequently satisfy it and prolong its sleep. 



Table No. .15. — Time for Feeding. 



From Birth to 
3 Months Old 


3 to 8 Months Old. 


8 Months Until 
1 Year Old. 


6.00 A. M. 

9.00 A. M. 
12.00 Noon 

3.00 P. M. 

6.00 P. M. 

9.00 P. M. 
12.00 Midnight 


6.00 P. M. 
9.30 A. M. 
1.00 P. M. 
4.30 P. M. 
8.00 P. M. 
12.00 Midnight 


6.00 A. M. 
10.00 A. M. 

2.00 P. M. 

6.00 P. M. 
10.00 P. M. 



1 1 am indebted to the chemist of the Walker-Gordon Laboratory for a series of 
chemical analyses herein reported. 



MATERNAL FEEDING. 85 

The first three or four days require special feeding methods. On the 
day of the birth, the exhaustion of the mother and presence of colostrum, 
besides the normal deficient quantity of food in the breast, demand large 
intervals of rest. Thus for the first three days (unless the milk-supply is 
profuse) putting the infant to the breast once in six hours is sufficient; if, 
however, the supply of milk is ample, then we can follow the table given 
above and nurse the infant every three hours. 

Maternal Feeding. 

The feeding of infants will always be a live question. It is simplified 
when maternal means are used. The plea, therefore, to resort to human milk 
feeding means not only to obviate the difficulties of home modification of 
cows' milk and the dangers of contamination, but it also means that we 
give the infant the proper start in life. The foundation must be strong, 
and such foundation depends on the growth and development of the organs, 
due to proper metabolism of fat, carbohydrate, and especially of the protein. 
Human milk contains an assimilable form of iron besides a given quantity 
of salts to be utilized in the growth of bone and teeth ; it is this lack of iron 
in cows' milk that renders it less nutritious. 

The virtues of human milk have been extolled from many infectious 
hospitals, where it is found that there is more vitality in an infant that 
nurses the human breast than in the infant reared by artificial means. The 
susceptibility to infections is far less in the infant nursed at the human 
breast than in the infant brought up by artificial means. What applies 
in infancy applies equally well in later life and there is no question in my 
mind that the breast-fed infant, being the stronger, will also be able to with- 
stand the infection of tuberculosis in later life. Our plea should, therefore, 
be primarily for the education of the mother, especially so for the mother 
who believes the modern fad of artificial feeding is equally as good as the 
natural method. 

Human milk contains a diastasic ferment. Peroxydase is found in 
cows' milk. Many cases require but several months for a proper start in life. 
The most critical period of an infant's life is the first three months ; hence 
it is imperative to start right. 

An infant is not born with a diseased stomach : it is born with a healthy 
stomach, with normal digestion, and with power to assimilate almost any 
kind of food. Any one who will study the digestive conditions of the first 
six or eight weeks of infantile life, will find that almost every type of food 
will be assimilated. If an excess of fat or protein is ordered the same will 
not show marked systemic disturbance until after the first six or eight 
weeks of life. Feeding formulae which would give rise to marked gastric 
disturbance during the third and fourth months are frequently well borne 



86 NUTRITION. 

and apparently digested during the first month of life. This is because 
we are dealing with a healthy gastric mucosa plus normal secretions, and 
because pathological conditions have not yet developed. This accounts for 
the tolerance of high fats and high protein in early infancy. 

Casein is a nucleoalbumin in a neutral combination with lime. Such 
casein will be precipitated on the addition of acid. It is not dissolved in 
milk, but exists therein in a colloid form. In addition to casein we have 
laetalbumin, which corresponds to serum-albumin. We also have lacto- 
globulin ; both are also present in colostrum. 

The albumin of milk if injected into a rabbit produces a serum which 
can give us the Bordet reaction. Alexins and antitoxins, in addition to sub- 
stances contained in the internal secretions, agglutinins, complements, are 
found in human milk and transferred thereto by the serum. According 
to Ehrlich, these substances give marked resistance and a distinct passive 
immunity to the infant. During the last few years a study of the physio- 
logical requirements of the infant has demonstrated the fact that our feeding 
rules and feeding intervals have been wrong, that the tendency to overfeed 
exists, and that the interval for proper assimilation between meals is too 
small; hence we must change our methods to give the infantile stomach less 
work and at the same time sufficient food for its development. 

An infant should nurse at birth seven times in twenty-four hours, or 
once every three hours. At one month the interval of three hours should be 
increased to three and one-half hours; thus, no more than five feedings by 
day and no feedings at night should be given. In special cases the infant 
may require feeding every two hours, but bear in mind that less frequent 
feedings stimulate a better flow of milk, give the infant a longer interval for 
digestion and thus an increased appetite. 

When scanty supply of human milk exists, then mixed feeding, alternate 
breast and bottle, may be given, but it is important to look upon the human 
milk as the most precious food, and every drop to be valued far more than 
the cows' milk that we use to supply the deficiency of the human breast. A 
close study of infantile stools during maternal feeding has shown that there 
are frequently tendencies to either constipation or the reverse, loose or green- 
ish stools. Neither of the above conditions should be regarded as serious 
factors and by no means should we look upon the human breast with dis- 
favor even though the stools do not correspond to that desired yellowish, 
pasty consistency. So many factors are at play, alkalinity of the intestine, 
or acidity of the intestine, likewise chemical alterations in the milk, and 
atmospheric or thermic influences inhibit the proper function of the glands 
so that the intestinal ferment may or may not perform its function. Such 
conditions must be borne in mind before a final conclusion to discard a human 
hreast of milk is reached. 



BREAST-FEEDING. 87 

Another point, and one frequently submitted, is, shall a woman continue 
to nurse her infant if she menstruates ? to. which one should reply that the 
condition of the infant is not affected by the presence of the function of 
menstruation, and human milk may be utilized as if the same were absent. 
The bacterial content of the intestine of an infant nursed at the human 
breast has far less pathogenic bacteria than the infant fed on cows' milk. 

Suggestions for Breast-feeding. 

The mother or wet-nurse should always sit upright, be it at night or 
during the day, while nursing the infant. 

Danger of Suffocation. — A great many cases are on record where the 
mother or wet-nurse has fallen asleep while nursing and smothered the in- 
fant. For this reason it is important that the infant should sleep in its 
own crib or bed, and should never sleep with the mother or nurse. 

Shall an Infant Receive but One or Both Breasts for One" Meal? — 
This depends on the infant's appetite. Some infants appear satisfied 
after nursing from one breast, and will let go of the nipple and fall asleep. 
Lightly tapping the cheeks of the infant will awaken it, or the withdrawal 
of the nipple from the infant's mouth will frequently arouse it to continue 
nursing. If, however, the infant will not renew its nursing, and still con- 
tinues to sleep, and if the infant has nursed steadily for ten minutes, then 
the sleep should not be disturbed. 

Length of Time for Nursing. — A good plan is to note the time when 
the nursing act commences and stops. No infant should nurse longer than 
twenty minutes, whereas frequently ten or fifteen minutes will suffice. If 
an infant nurses more than twenty minutes, say thirty or forty minutes, 
then we may be sure that the breast-milk is deficient in quantity and a 
specimen should at once be submitted for a proper chemical examination. 

Scanty Breast-milk Bequiring Mixed Feeding. 

When there is a deficiency in the quantity of breast-milk, but the quality 
is good, then it is advisable to feed the infant alternately with breast-milk 
and bottle-milk. At the same time it is advisable to direct attention to the 
mother's general condition, and see if we cannot tone her up, and thus im- 
prove both quality and quantity of her milk. Frequently a subnormal or an 
anaemic condition requires iron. A day's outing to the country or seashore, 
with moderate exercise, will stimulate and increase the flow of milk. Every 
drop of breast-milk is so precious that no infant should be deprived of it, 
and wise is the physician who will insist upon giving all breast-milk. When 
there is deficient lactation, supply the deficiency by giving a properly diluted 
milk or cream mixture, adapted for the age and weight of the infant. 



SS NUTRITION. 

To Increase the Quantity of Breast-milk. — Some of the galactagogues 
have given me satisfaction, in addition to a nutritious diet, such as meat, 
milk, and eggs. A preparation on the market known as Nutrolactis 1 has 
proven a most valuable galactagogue. It is given in tablespoonful doses 
three times a day. This will not only stimulate the quantity, but also the 
quality, of the milk. Grandin and Jarman, in their text-book on "Obstet- 
rics," recommend the strong infusion of galega officinalis when the flow of 
milk is scant. This is to be ordered in tablespoonful doses three or four 
tinies a day. Malt tropon, one teaspoonful three times a day, after meals 
will stimulate the flow of milk. 

Somatose in Cases of Deficient Lactation. — "A priinipara who secreted only a 
limited amount of colostrum, and kept that up so that the child was crying from 
hunger and had to be artificially fed, was put upon somatose, 4 teaspoonfuls a day, 
and in three days the patient secreted a sufficient quantity and quality of milk to 
satisfy the child, which increased one-fourth of a pound regularly each week. It 
seemed difficult to induce the mammary glands to perform their proper function; 
but when somatose was given there was a normal supply of milk, and the child was 
properly nourished without artificial feeding." 

Do Drugs Taken by a Nursing Woman Affect the Baby ? 

Physiological experiments have frequently demonstrated the fact that 
a great many drugs can be given to an infant through the milk; thus,' opium 
and morphine and narcotics in general do affect the infant, when taken by 
the mother. Baginsky calls attention to this fact in his text-book on "Dis- 
eases of Children": "Alcohol, when taken by the mother, is transmitted 
through the milk, but not in very large quantities. The following is a list 
of drugs which have been found in milk : The purgative principles of rhu- 
barb, senna, and castor-oil ; the metals, antimony, arsenic, iodine, bismuth, 
lead, iron, mercury; the volatile oils, like copaiba, garlic, and turpentine; 
also salicylic acid, and the iodides and bromides." Do not give cocaine, 
chloral, atropine, or hyoscyamus. Care is to be used with the following: 
Digitalis, antipyrin, and ergot. An unpleasant flavor can be imparted to 
the breast-milk by the mother or wet-nurse eating onions, turnips, cauli- 
flower, or cabbage. 

Disturbances During Breast-feeding. 

Quite frequently we meet with gastro-intestinal disorders in infants 
that are wholly breast-fed. These disturbances are due to (a) insufficient 
exercise; (b) faulty diet; (c) extreme nervous irritability; (d) menstrua- 
tion while nursing; (e) physiological changes in the woman, causing an 
improper ratio of ingredients. Some of the causes just mentioned can easily 
be remedied. On the other hand, a very nervous woman, whose anxiety keeps 
her constantly fretting during the day and awake at night, will hardly be 

1 Sold in all drug stores 



BREAST-FEEDING. ' 8J> 

adapted for breast-feeding, and the sooner the infant is removed from such 
a breast, the better for the infant. 

The following cases will illustrate the above conditions: — 

An infant was nursed by its mother. The mother was extremely nervous, 
fretful, did not sleep at night, and nursed her child too often. 

The infant suffered with colic, had greenish, cheesy stools, and did not gain in 
weight. Had indigestion and all evidence of intestinal colic. The case was seen 
by me through the courtesy of Dr. A. A. Richardson, of New York City. The physi- 
cian assured me that the mother would not leave her home, and that she had had 
no outdoor exercise, no fresh air, and nothing but the constant worry of a sick, crying 
baby which she nursed as best she could. A chemical examination of the breast- 
milk showed the following: — 

Fat 1.20 

Sugar 6.50 

Protein 1.70 

. Ash 0.18 

Total solids ' 9.58 

Under the influence of exercise and careful diet the fat was increased. In this 
case we alternated breast and bottle feeding, and gave the child mixed feeding. A 
formula of 2 per cent, fat, 5 per cent, sugar, and 0.75 per cent, protein was pre- 
scribed at the Walker-Gordon Laboratory. 

An infant one month old was seen by me in the family of Dr. J. Grosner, of 
this city. The infant had been vomiting, had had colic, and was very restless. The 
mother was very nervous, but had an abundance of milk. From the history I 
learned that the child had had an explosive vomit, the food coming out, besides large 
quantities of gas. There were five to seven stools in twenty-four hours. The bowels 
moved at each nursing. The chemical examination of the breast-milk showed: — 

Fat 4.00 

Sugar 6.50 

Protein 3.05 

Ash 0.30 

Total solids 13.85 

From this examination it can be seen that for a baby six months old 
there was an excess of fat and also a very high percentage of protein. 

An infant one to two months old requires 2 per cent, of fat. Note also 
a normal infant receives between 1 and 1% P er cent, of protein, while this 
child received more than 3 per cent, of protein. There being a profuse 
secretion of milk, the child received far more than it could digest in both 
quality and quantity. The feeding interval was lengthened, and the time 
of nursing was reduced to five minutes, whereas until the appearance of 
vomiting the child nursed twenty minutes. An ounce of sterilized water was 
ordered immediately after each nursing, hoping to tnus dilute the milk. 
This method proved successful. 



90 



NUTRITION. 



A Case of Prolonged Lactation, Showing Deficiency of Nutriment. — A child, 
about 1 year old, was brought to me with the following history: It has no teeth. 
Can neither stand nor walk. It is colicky. Does not sleep well. Does not gain 




Fig. 29. — Showing a Drop of Milk under the Microscope. Note the 
poor character of this emulsion, the uneven fat-globules, and their irregular 
size and distribution. The infant nursed with the above milk was rachitic 
and colicky. Although 15 months old, no tooth had appeared. The mother 
of the infant states that she menstruated every twenty-one or twenty-two 
days since her infant was born — during this present nursing period. 
(Original.) 




Fig. 30. — This Drop of Breast-milk is from a very Anemic Woman. 
The child was extremely emaciated, had greenish stools and colic, and was 
always crying. Note the uneven character of above emulsion, when com- 
pared with Plate VII. The infant was poorly nourished; had rickets and 
marked cranio-tabes. Mixed feeding was resorted to, with decided improve- 
ment. (Original.) 



weight. The child was nursed every three or four hours. The mother was very 
nervous, and menstruated almost every month during lactation. The chemical anal- 
ysis of the milk gave: — 

Fat 1.22 

Sugar 7.07 

Protein 0.98 



BREAST-FEEDING. 



91 



It was very evident that this baby was receiving poor milk, very low fat, and 
deficient protein. The infant was weaned, artificial feeding was prescribed, and the 
infant immediately showed a gain in weight. The symptoms of colic disappeared. 

Illustration of Prolonged Lactation Without Apparent Harmful Effects. — An 
infant fifteen months old was brought to me for the relief of constipation. It had 
ten teeth, was able to stand and walk, and was beginning to talk. The infant was 
still breast-fed. The analysis of the milk gave the following: — 

Fat 2.86 

Sugar 6.78 

Protein 1.76 




Fig. 31.— Holt's Milk Test Set, for Testing Human Milk. 



The infant's weight in this case was normal, and I must regard this 
prolonged lactation, showing such good results, as an exception rather than 
a rule. 

Additional Foods During the Nursing Period. 

Between the sixth and eighth months, if the infant is thriving and 
gaining in weight, cereal feedings should be added. A small saucer of 
farina, or cream of wheat steamed with water, for two hours, and served 
with skimmed milk and. a small quantity of sugar, should be given before 
the 10 a.m. feeding. This cereal feeding may be given daily if there are 
no symptoms of starch indigestion, such as flatulence, colic, or distended 
abdomen, noted. At twelve months the yolk of a raw egg may be added to 
the cereal. Additional foods which may be given to an infant after the teeth 
erupt, or between the seventh and twelfth months, are : Two ounces of 
expressed beef juice over a small saucer of steamed rice; a piece of rusk or 



92 NUTRITION. 

biscuit after the bottle. A coddled egg at noon may be tried when the 
infant is one year old, and if it agrees, it may be ordered every other day. 

The Management of the Nipples Before the Baby is Born. 

It is very important during the last few months of pregnancy to devote 
considerable time and attention to the condition of the nipples. If these 
be found long and round, well projecting, then it is advisable to try to harden 
them, because the irritation from the child will cause considerable trouble 
unless we seek to prevent this. 

Oni, in treating the question of sore nipples, said at the Medical 
.Society, 1 that one out of every two nursing women was affected with 
lesions of the nipples. The determining cause of the fissures was macera- 
tion of the epiderm under the double influence of the saliva of the infant 
and the milk which flowed during the intervals. The epiderm exfoliated 
and the derm exposed became excoriated; the lesion thus produced became 
infected, and, instead of healing, progressed in extent. The predisposing 
causes were short and inextensive nipples and want of cleanliness. The 
primiparge were affected with fissured nipples to the extent of 59 per cent. 

The prophylactic treatment consisted in astringent lotions during 
pregnancy, while after delivery the nipple should be washed with boric 
acid lotion before and after suction, the application of an antiseptic 
dressing during the intervals of nursing. The curative treatment, to be 
radical, consisted in the suspension of nursing, which, although excellent 
for the mother, would be deplorable for the child. The list of agents 
employed against the fissure was very lengthy, indicating their uselessness. 

In summer cold water will be found more agreeable, with a small quan- 
tity of alcohol. If the nipples are very small and flat, and do not protrude 
properly, then suction by means of a breast-pump, applied directly over the 
breast, will draw them out. In some instances an ordinary clay pipe which 
has a smooth bowl, the bowl to be laid over the nipple and the stem to be 
sucked or drawn, is satisfactory. This is to be repeated every few days. 
A few minutes of drawing out will suffice until the nipples are sufficiently 
prominent. Biedert 2 gives the following prescription for hardening the 
nipples : — 

Tannic acid 1 teaspoonful 

Red wine 8 ounces 

If red wine is not handy, then substitute brandy in its stead. This is 
to be applied after thorough washing with soap and water, and removing 
crusts, if they are present. 

Tender Nipples. — If, while nursing, the nipples crack and blood oozes 
from them, or if, from irritation of the child's gums biting them, the nipple 

x Paris Cor. Med. Press and Circular. 

2 "Kinderernaehrung," fourth edition, 1900, page 110. 



BREAST-FEEDING. 93 

is sore, then it is a good plan to allow the child to nurse through a nipple- 
shield. (See Fig. 32.) 




jjf 

Fig. 32. — Nipple-shield for Relief of Tender Nipples. 

Nipple-shields can be used during the nursing act, and immediately 
thereafter the following salve can be smeared on the nipples: — 

Ifc Zinc oxide 1 drachm 

Vaseline 1 ounce 

TREATMENT OF TENDER NIPPLES (GARRIGUES). 

IJ Orthoform 1 drachm 

Lanoline 1 ounce 

M. Sig.: Apply. 




Fig. 33. — Breast-pump. 



Breast-pump. 



The breast-pump (Figs. 33 and 34) is a valuable addition to the nur- 
sery. It should be kept scrupulously clean by immersing it in boiling water 
containing a pinch of table-salt. In drawing a specimen of breast-milk for 
a chemical examination the breast-pump is very useful. If an infant is ill 



94 NUTRITION. 

and refuses the breast — as, for example, if it has rhinitis or cold in the head, 
nasal obstruction, preventing it from breathing while the nipple is in its 
mouth — it generally will take the breast and immediately let go of it again. 
If the breast-pump is properly applied, and the required quantity of milk 
drawn off, the infant can be fed slowly with a spoon. 

In a serious condition — as, for example, in a severe case of pneumonia 
with loss of appetite — the life of the child may depend on forced feeding. 
This is described in the section on "(ravage." It is very . important to 
have the cup or any other receptacle into which we draw the breast-milk 
properly sterilized; otherwise the breast-milk will be infected in the same 
manner as is described in detail in the chapters on "Cows' Milk" and 
"Bottle-feeding." 




Fig. 34. — Breast-pump. 

Massage of the Breast During Lactation. 

Caking. — The "caking," or hardening, of the breast is not due to cur- 
dling of the milk. This never takes place within the milk-tubes. Neither 
is it due to the presence of milk, for as a rule no milk is formed until 
nursing begins, or if any, but a very small amount. The hardening of 
the gland is due to the congestion of the blood and lymph, and therefore 
massage should be directed to the removal of these, and likewise should 
be centrifugal in direction, and not aim to the removal of the milk by centrip- 
etal stroking. The blood-supply of the gland is mainly derived from the 
subclavian and axillary arteries ; the venous outflow and the lymph discharge 
are by corresponding channels, and this is the anatomical basis for action. 
The massage should begin gently below the clavicle and in the axilla, and 
gradually encroach more and more on the mammary region. By this method 
a hard and painful breast is rendered lax and comfortable without the dis- 
charge of any milk. The writer does not recommend this treatment where 
there is infection or true inflammation, as in mastitis; in such conditions 
rest is indicated, and nothing should be done which will tend to spread the 
infection. 1 

The Diet of a Nursing Mother. 

Immediately after the birth of the child the exhausted condition of a 
woman following labor will certainly call for rest ; hence sleep is imperative, 
after which some form of stimulation is required. This can best be accom- 

1 See an elaborate paper on this subject by Bacon in American Journal of 
Obstetrics. 



DIET OF A NURSING MOTHER. 95 

plished by giving at intervals of several hours good, wholesome food, as 
chicken broth or beef broth, weak tea, or strained gruel. It is unnecessary 
to state that each woman's case and her former habits must be taken into 
consideration in prescribing a diet. If labor has been normal, then the nour- 
ishment will stimulate the milk. -If warm liquids are not well borne, then 
cold drinks like buttermilk, koumyss, zoolak, or iced tea should be em- 
ployed. Iced champagne will frequently do more good to allay gastric irrita- 
bility than all medication. Paw milk in combination with seltzer or lime- 
water is indicated. In some instances ice-cream will aid nutrition and alle- 
viate gastric irritation. If the pelvic condition is normal, then it is wise 
not to give solid food for the first three days, but, rather, stimulate the milk- 
glands by giving meat broths, farinaceous gruels, and by all means milk. 
Zwieback soaked in milk or in tea is highly nutritious and easily digested. 
Other nutritious foods are calfsfoot jelly and chicken jelly. 

After the third day, if the pelvic organs are normal, it is wise to con- 
sider the action of the bowels. If the bowels have not moved by this time, 
then buttermilk added to the diet or stewed prunes or peaches, baked apples, 
or grapes will aid in establishing a movement of the bowels. 

If the milk is scanty and the bowels have not moved, then the best 
remedy is a large tablespoonful of palatable castor-oil, modified to suit 
the taste by the addition either of lemon juice or orange juice, or by adding 
several drops of the ordinary spirits of peppermint. After the bowels have 
been evacuated and the general condition warrants it, then a diet consisting 
of the following is indicated :— 

BREAKFAST, 7 TO 8 A.M. 

Hominy and Milk. Grapes. 

Farina and Milk. . Soft-boiled Eggs. 

Rice and Milk. Poached Eggs. 

Oatmeal and Milk. Eggs on Toast. 

Germea and Milk. Coffee and Milk. 

Cream of Wheat and Milk. Tea and Milk. 
Some Stewed Prunes, Figs, or Cocoa and Milk. 

Peaches. Toast and Butter. 

Stewed Apples. Stale Bread (2 days old), with 

Oranges. Butter. 

I do not advise meat or fish in the morning, unless the nursing mother 
has always been accustomed to this form of diet. 

LUNCH, 12 TO 1 P.M. 

Some soup made from meat, either veal, beef, mutton, lamb, or chicken, 
containing also some rice, barley, farina, sago, or hominy; it should not 
be highly seasoned, and should not be strained. 



9(3 ' NUTRITION. 

Fish, boiled or fried, and all shell-fish, particularly oysters, are very 
nutritious during the nursing period. 

If the appetite warrants it, then a piece of steak or chop, roast beef, 
chicken (white meat only), or raw chopped meat, with bread and butter, 
is very nutritious. 

EVENING, 6 TO 7 P.M. 

A Bowl of Oatmeal Gruel. Junket. 

Stewed Oysters. Cup of Tea. 

A Drink of Milk. Eggs, if desired. 

Farina Pudding. Meat, if in the habit of eating 

Eice Pudding. it in the evening. 

Cornstarch Pudding. 

For Thirst. — Cool, filtered water, or the alkaline waters, like Seltzer 
and Apollinaris. 

If the milk is scanty, the flow can be stimulated by drinking a cup of 
hot broth, made from beef /chicken or veal, lamb or mutton, several minutes 
before putting the child to the breast. 

Alcoholic Drinks. — If the woman is in the habit of drinking wine or 
beer, then it is unwise to discontinue the use of alcoholics in moderate 
quantities while she is nursing. I have seen a great many women whose 
flow of milk was scant who immediately secreted an abundance of milk 
after partaking of a glass of beer, or ale, or porter with their meals for sev- 
eral days. Beer has a decided laxative effect, and this in itself is rather an 
advantage for those nursing mothers having a tendency to constipation. So 
my rule, therefore, would be to insist on abstinence from wine and beer 
unless the patient has been in the habit of taking it formerly. 

FOODS TO BE AVOIDED BY A NURSING WOMAN. 

Onions. Ethereal Oils. 

Garlic. Butter and Fat moderately. 

Cabbage. Candies and too much Sweets. . 

Powerful Salts (Eochelle, Glau- Large quantities of Potatoes, 
ber, Epsom). 

Inability of Mothers to Nurse their Children. 

It is surprising to note the gradual disappearance of the healthy, robust 
American mother who can perform the duty of nursing her infant. The 
following table will give a fair illustration of the conditions as they exist in 
New York City to-day : — 



WET-NURSE. 97 

Table No. 1G. — A study of 1000 Mothers and their ability to nurse. 



Mothers. 


Condition 

of 
Mother. 


Able to Nurse 

9 Months to 

1 Year. 


Able to Nurse 
4 Days to 
2 Months. 


Primiparas. 


Multiparas. 


500 1 


Living in Tene- 
ment Houses. 












Very Poor. 


450 2 


50 


210 


290 


500 


Living in 

Healthful 

Portions of 












the City. 
Prosperous. 


84 


150 


305 


195 



According to the above "statistics, 90 per cent, of the poor mothers are 
able to nurse their children, while only 17 per cent, of the rich mothers 
are able to perform the same duty. 



Wet-nurse. 

Two important points are necessary: First, the presence of suitable 
milk ; second, the absence of a constitutional taint 3 or acute severe illness. 

What to Examine. — First, the breasts for the quantity of milk present. 
The breast should be gently but firmly held at some distance from the 
nipple; thus we can learn by palpation regarding the parenchyma of the 
glands. Also the quantity of milk, which, if expressed continuously about 
twenty to thirty seconds, should flow in several streams. 

Stagnant milk always shows sensitiveness on pressure. The statement 
of a wet-nurse that her "milk is deficient in quantity" can be determined by 
subjecting her to careful observation for several hours. After this time the 
milk in the breasts should be expressed and the quantity determined. 

The ease with which milk can be expressed by palpation is an impor- 
tant factor to note. If the milk flows with great difficult}', and requires 
considerable massage or pumping, then such a nurse is totally unfit to nurse 
atrophic, marasmic, or prematurely born babies. 

Weak or marasmic children require a wet-nurse having a plentiful 
supply of milk, so that the slightest effort while nursing will result in 
a liberal flow of milk. 



1 Thirty-five, or 7 per cent., of these mothers suffered from puerperal disease, 
such as septicaemia, mastitis, and kindred affections; hence, they were ordered by 
their physicians not to nurse. 

2 Three hundred and twenty-four infants were put on artificial feeding. This 
feeding consisted of feeding at the laboratory and home modifications. One hundred 
and fifty-four of these infants were supplied with wet-nurses, owing to loss of 
weight, dyspeptic conditions, or marasmus during the bottle-feeding. 

8 The blood of every wet-nurse should be examined for a Wassermann reaction. 
The danger of transmitting syphilis demands this precaution. 



98 NUTRITION. 

Note if the expressing of milk causes pain; in the normal breast it 
should be painless. 

It is not always the quality of the milk, but frequently the quantity, 
that is the cause of poor assimilation of a wet-nurse's milk. In such in- 
stances a chemical examination of the milk is imperative; by this we can 
learn exactly how much we feed an infant in percentages. If necessary, 
we can modify the milk (by proper wet-nurse diet) until the required per- 
centages are attained. 

The Child of a Wet-nurse. — Certain allowances must always be made 
for babies presented by wet-nurses — for instance, if the hygienic surround- 
ings of a wet-nurse are very poor, and in addition thereto her food supply 
is meager, then a general anaemic appearance must be expected. On the 
other hand, a healthy, robust-looking baby must not be regarded as the 
criterion by which we should judge the wet-nurse. 

The tricks of wet-nurses are manifold. Frequently they will procure 
a healthy-looking infant and pass it off as their own, in order that they may 
procure a position. 

Another point is that they will frequently resort to stuffing their babies 
by feeding a bottle in addition to their breast-milk. Thus we must judge 
for ourselves the quality of the wet-nurse physically, and, most important 
of all, by the quality and quantity of her breast-milk. . 

Health of the Wet-nurse. — It must be borne in mind that the secretion 
of milk does not so much depend on her constitution as it does depend on 
her nervous system. Great importance must therefore be placed on the 
uselessness of hysterical or neurasthenic women for wet-nursing. 

The phlegmatic temperament — the broad-shouldered, easy-going woman 
— pleasant and gentle-mannered, is the one most useful and best adapted for 
wet-nursing. 

Wet-nurses with Goiter. — Bezy, of Toulouse, considers the question: 
Should women affected with goiter be accepted as wet-nurses ? He does not 
think so because there is a certainty of danger for the infant, but because it 
is more prudent to exclude such women from nursing. In 1897 he saw a 
fatal case of tetany in an infant aged six months in which no cause could 
be found for the disease except the fact that the mother who nursed this 
baby had exophthalmic goiter. A few months later he saw another case of 
the same kind, and in 1898 he saw a case of tetany in an infant aged three 
months, who died after an illness of about forty days and whose nurse had 
simple goiter. The author thinks that tetany in infants may be of thyroid 
origin, and that the thyroid affections of the nurse are transmitted to the 
nurslings. He does not pretend to establish an invariable law, but simply 
wishes to call attention to the possibility of such transmission and to suggest 
further investigations on the subject. 

We should reject a wet-nurse as unfit for nursing if she has : — 



WET-NURSE. 99 

1. Enlarged cervical glands. 

2. A goiter. 

3. Diseased lungs, no matter how trivial. 

4. Evidences of syphilis, such as a positive Wassermann reaction, or 
condylomata. 

5. Condylomata on her genitals. 

6. Mastitis. 

7. Carious teeth. 

Eecurring menstruation is no contraindication for a wet-nurse. Some 
women are perfectly healthy and will menstruate regularly during their 
period of wet-nursing, without harm to the infant. 

Erosions or fissures on the nipple should not he looked upon as contra- 
indications for wet-nursing. Infants will thrive, although changed from 
one wet-nurse to another. Breast-milk is not uniform in its consistency. 
We know that its ingredients not only change from day to day, but that the 
milk varies several times a day. In spite of this fact children thrive, as 
was demonstrated by Schlechter, who used 400 children in the Vienna 
Foundling Asylum. Among these an epidemic of gonorrhceal ophthalmia 
developed, requiring isolation. Thus, several nurses were ordered to he 
isolated with these infected children, and it was noted that these children 
developed just as well in spite of the change from their previous hreast-milk. 

The mortality in this same institution resulting from feeding with 
sterilized milk has been entirely done away with since the introduction of 
wet-nursing. 

Finally, it is important to note that it is the quality of milk, rather 
than the quantity, which determines the value of breast-milk. 

When children are strong and well-built, and have a ravenous appetite, 
they require a slow-flowing breast-mill- , as a rapid flow of breast-milk, aided 
by a hearty appetite, will tend to overload the stomach, and is one of the 
reasons for dyspepsia in young children. 

It is a good point to try to secure a wet-nurse suckling a child about as 
old as the one we wish her to nurse, although it is quite common to find 
nurses who have older children than the one they wish to nurse, and to find 
the latter doing well. 

The proof of the usefulness of + he wet-nurse is the condition of the baby 
after some time. If the child thrives it will increase in weight. Hence 
scales must be frequently used. The milk should be examined by a chemist 
to determine the percentage of ingredients. 

Especial note should be made of the percentage of fat and proteids. 

If a very quick examination is required, then a microscopical examina- 
tion of one drop of middle-milk will show the character of the fat globules. 

The rough method of examination is useful when the life of the infant 
is at stake and it is necessary to determine quickly whether or not a given 
wet-nurse is suitable for an infant. If a baby suddenly appears colicky or 



100 NUTRITION. 

does not gain in weight while wet-nursing, then a chemical examination of 
the breast-milk is imperative. We can frequently find an excess of fat or, 
more often, an excess of proteids as the cause of colic. 

Von Bunge presents the results of an investigation in which he shows 
that the increasing inability of mothers to nurse their infants is a matter 
of inheritance. He obtained information relative to 665 cases with the 
following result : The daughter was able to nurse her offspring in 182 cases. 
The mother was able in 99.2 per cent., and unable in only 0.8 per cent. 
The mother was able in 237 cases. The daughter was able in 53.2 per cent., 
and unable in 46.8 per cent. The daughter was unable to nurse her off- 
spring in 483 cases. The mother was able in 43.2 per cent., and unable in 
56.8 per cent. The mother was unable in 147 cases. The daughter was 
unable in 99.3 per cent., and able in 0.7 per cent. 

He concluded from the foregoing figures that inability to nurse is 
largely a matter of inheritance. Further inquiries also led him to believe 
that tuberculosis and nervous diseases were to a considerable extent asso- 
ciated with inability to nurse one's offspring. But much more prominent 
appears to be the relation of intemperance. Where the mother and daughter 
were both able to nurse he found that the fathers were usually at least mod- 
erate, in the use of alcohol, and only in 4.5 per cent, were they hard drinkers. 
On the, other hand, when the mother was able to nurse, but the daughter 
was unable, it was found that the father was often intemperate, and in 46.8 
per cent, was an actual drunkard.. In this inquiry the author considered 
those only as able to nurse who could nurse all their children for a period 
of nine months. All others as unable. 

The control of wet-nurses was very adequately discussed 1 as a public 
prophylaxis. Many believed it was a matter that could be brought under 
the control of the law. 

Dr. Petrini, of Galatz, professor at the University of Bucharest, pre- 
pared an elaborate report in which the prevalence of infection of syphilis by 
means of wet-nurses was demonstrated. He showed that its frequency varied 
widely in different countries, and hence an English view, for instance, of its 
comparative importance, drawn from the rarity of the infection in that 
country, was not a criterion for the whole, since it had been shown for 
Oriental lands, and even for Paris, that it was an important element. 

He proposes a special medical- service, working in co-operation with 
municipal authorities and having for its head a competent syphilographer. 
All children being nursed by wet-nurses should be inspected regularly by 
representatives of this bureau, and all wet-nurses should receive authoriza- 
tion for their calling by the same bureau after rigorous medical examina- 
tion. Special provision .should be made for syphilitic children. 



1 Second International Conference for the Prevention of Syphilis and Venereal 
Diseases, held at Brussels, Belgium, September 1 to 6, 1902. 



WET-NURSES' MILK. iQl 



Clinical Illustrations of the Variations in Wet-nurses' Milk. 

The following case will illustrate the peculiarity of breast-milk in a 
wet-nurse : — 

Case I. — First examination of breast-milk showed: — 

Fat 2.50 

Milk-sugar 6.50 

Protein 1.93 

Mineral matter 0.21 

Total solids 11.14 . 

Water 88.86 

When the wet-nurse was first employed, the infant gained more than eight 
ounces each week. Had yellowish stools, one or two each day. Slept well after 
nursing and appeared satisfied. Cried only at feeding time. Mo evidence of colic. 

A second examination of the breast-milk was made to compare the character of 
the milk with that of the first specimen: — 

Fat 2.10 

Milk-sugar 6.50 

Protein 1.41 

Mineral matter 0.15 

Total solids 10.16 

Water 89.84 

Two months later, same wet-nurse. Child's weight stationary. Green, curded 
stools; cries and has colicky pains. Restless at night. Wet-nurse is menstruating. 
Chemical analysis of milk shows: — 

Fat 0.65 

Milk-sugar 6.50 

Protein 1.12 

Mineral matter 0.11 

Total solids 8.38 

Water 91.62 

With the aid of cereals and malt, also a change from the city to the seashore, 
the milk improved. The infant was more satisfied. The stools again assumed a 
yellowish color. One month after this building-up treatment, an analysis of the 
breast-milk showed: — 

Fat 3.50 

Milk-sugar 6.50 

Protein 1.90 

Mineral matter 0.19 

Total solids 12.09 

Water 87.91 



102 NUTRITION. 

When the infant was eight months old the secretion of milk was scanty, so 
that the breast was alternated with bottle-feeding. The general condition improved. 
The child was again satisfied. A chemical examination of the breast-milk showed: — 

Fat 3.00 

Milk-sugar 6.50 

Protein 1.08 

Mineral matter 19 

Total solids 10.77 

Water 89.23 

As the proteins were found to be very low, I ordered the white of a raw egg, 
soup, and expressed beef juice. When the child was nine months old it was neces- 
sary to wean it, as the wet-nurse had very little milk. 

Iii this case the stationary weight, the colicky condition, and the char- 
acter of the stools were important guides, and fully agreed with the analyses 
of the specimens given. 

Case II. — Colic. — An infant five months old suffered with severe colic. It cried 
continuously, especially after nursing. Relief was afforded when castor-oil was given 
or when warm colon flushing was resorted to. Diluting the breast-milk by giving 
an ounce or two of barley or rice water immediately after each nursing seemed to 
modify, but not altogether relieve, this condition. The chemical examination of 
the milk gave: — 

Fat 6.59 

Sugar . . 6.69 

Protein ... 1.16 

Ash 19 

Total solids •. . 14.63 

Water 85.37 

The excessive amount of the fat teas evidently the cause of the trouble. The 
quantity of meat was reduced. Exercise was ordered and beer forbidden. In a few 
weeks the percentage of fat in the milk was greatly reduced, and the infant far 
more comfortable. 

~ c~ 

Oco 

o O a o q, 



'Polo <*>■*<* O 






o° o 
o 

o o " o-yr*p- o^o 

°°° ° o °° « °V 

Poo. *o, * q o 00 o° 
0° o o. 

o Q, o n o ° - ° 



O °°o * ° 



o*o ot> o oo 
o o 



Case III. — Fig. 35. — Specimen of Breast-milk Taken from a Wet-nurse during 
Menstruation, Illustrating the Poor Character of the Emulsion. (Original.) 



DIET OF A WET-NURSE, 103 

The infant was very restless, and had colicky attacks. Note the small, un- 
evenly divided fat globules — irregular form of the larger globules. It appears to 
be a very watery emulsion. Chemical examination of the specimen showed: Fat, 
1.60; sugar, 6.50; protein, 2.43. The baby did not gain during the whole week. 

Case IV. — Good Milk in a Wet-nurse. — In this case we have a child that was 
gaining in weight. Appeared satisfied after nursing, but had a tendency toward con- 
stipation. A chemical analysis of the milk gave: — ■ 

Fat . . . .* 4.20 

Sugar 6.50 

Protein 2.80 

Ash 28 

Total solids 13.78 

Water 86.22 

Diet or a Wet-nurse. 

The diet given for a nursing mother can also be used as a guide in 
choosing the diet for a wet-nurse. The greatest care, however, must be 
bestowed on the manner of living. 

Manner of Living. — A wet-nurse that was a former servant, or worked 
out of doors, and is suddenly taken into this new mode of life and given 
charge of a baby, must have proper exercise. Otherwise she will very soon 
secrete milk which will be totally unfit for an infant, and as a result the 
child will probably have severe colic and irregular, cheesy stools; will vomit 
excessively, and will not gain sufficiently in weight. It is therefore impor- 
tant to try to adapt a wet-nurse to the same condition as existed prior to 
her pregnancy; so that both her manner of living and, chiefly, her diet 
shall not be different. 

That alcohol may be eliminated from milk is shown by a case reported by Val- 
lani. A nursing infant was seized with convulsions with great regularity on Mon- 
day and Thursday, but was quite well on other days. Investigation showed that 
the wet-nurse on Sundays and Wednesdays (her days out) was in the habit of drink- 
ing freely of alcohol. The curtailment of these privileges resulted in the disappear- 
ance of the convulsions. 

Proper Best. — To be equal to her task a nurse must be given plenty 
of sleep, if it is at all possible. 

Adriance, in the Archives of Pediatrics, says: 

1. Excessive fats or proteins may cause gastro-intestinal symptoms in 
the nursing infant. 

2. Excessive fats may be reduced by diminishing the nitrogenous ele- 
ments in the mother's diet. 

3. Excessive protein may be reduced by the proper amount of exercise. 

4. An excess of protein is especially apt to cause gastro-intestinal symp- 
toms during the colostrum period. 



1Q4 NUTRITION. 

5. The protein, being higher during the colostrum period of prema- 
ture confinement, presents dangers to the untimely born infant. 

6. Deterioration in human milk is marked by a reduction in the pro- 
tein and total solids, or in the protein alone. 

7. This deterioration takes place normally during the later months of 
lactation, and unless proper additions are made to the infant's diet, is 
accompanied by a loss of weight or a gain below the norma: standard. 

8. When this deterioration occurs earlier, it may be the forerunner of 
the cessation of lactation, or well-directed treatment may improve the condi- 
tion of the milk. 

Methods of Changing the Ingredients in Woman's Milk. 

Botch gives a condensed table for these changes as follows : — 

To Increase the Total Quantity. — Increase the liquids in the mother's 
diet, especially milk (malt-extracts may be helpful), and encourage her to 
believe that she will be able to nurse her infant. 

To Decrease the Total Quantity. — Decrease the liquids in the mother's 
diet. 

To Increase the Total Solids. — Shorten the nursing intervals, decrease 
the exercise, decrease the proportion of liquids, and increase the proportion 
of solids in the mother's diet. 

To Decrease the Total Solids. — Prolong the nursing intervals, increase 
the exercise, and increase the proportion of liquids in the mother's diet. 

To Increase the Fat. — Increase the proportion of meat in the diet. 

To Decrease the Fat. — Decrease the proportion of meat in the diet. 

To Increase the Protein. — Increase the exercise up to the limit of 
fatigue for the individual. 

It is wise in all cases of disturbed lactation, whether in maternal or 
wet-nursing, to make efforts in accordance with these rules to produce a milk 
that is suitable for an infant who is not thriving, before changing to any 
other method of feeding. 

Wet-nursing. 

It is an established fact that the best possible food for an infant is 
breast-milk. Where the mother of an infant is prevented from nursing 
her child, the next thing to be considered is wet-nursing. That nursing a 
child is an advantage to the mother is a well-known fact, inasmuch as it 
influences the contraction of the uterus and stimulates the circulation. 
Contrary to the belief that nursing a child is detrimental and contraindi- 
cated in women whose lungs are weak and who have a tendency to tuber- 
culosis, it does them no harm, and, indeed, seems to do them good. This 
statement is borne out by the experience of Dr. Heinrich Munk, of Karls- 
bad, Austria, a specialist in the diseases of women. 



WET-NURSING. 105 

In Austria the state supports public institutions for lying-in women. 
They are kept there and confined gratis, and remain about fourteen days. 
They are admitted into these hospitals in the last months of pregnancy. 
Vienna usually has about 300 women on hand. Prague constantly has 100 
women in this condition, who are utilized for the purpose of instruction to 
physicians and midwives. 

In Prague there are about 3000 women confined annually, and these 
women are put into the foundling asylum. There they remain until they 
procure a place as a wet-nurse or as long as their services are needed in the 
asylum. When wet-nurses are taken from the foundling asylum, it is a 
frequent occurrence to have those remaining therein nurse at least two chil- 
dren, and frequently three, at one time. In this manner they dispense grad- 
ually with these wet-nurses without hurting the remaining children. Many 
children die, some of them intrapartum in operative confinements, and the 
women (mothers of such children) are then utilized for wet-nursing. It 
is a rule to keep the children in the asylum until they have attained a little 
over 4 kilograms (about 9 pounds), and they are then put out for further 
feeding (artificial feeding), for which the city pays about 12 florins ($5.00) 
a month. The children remain usually until they are 6 years old, and are 
then given back to their own mothers. Many of these children die; others 
are adopted by those who have reared them, but the greater portion are 
taken back to their own mothers. In Vienna there are about 10,000 con- 
finements annually in the public institution. There are a great many cities 
in Austria — like Innsbruck-Olmutz, Brunn, Linz, and Klagenfurt — where 
there are at least 200 confinements annually. In Vienna a wet-nurse receives 
30 florins per month, for which she is sent (railroad expenses paid) to 
whoever requires her services. She is taken on trial for fourteen days to see 
if she is adapted for her place. A wet-nurse can be procured by sending a 
telegram and a money order any day during the year. The customary wages 
are from 12 florins upward per month. Each wet-nurse is carefully exam- 
ined by the professor before she is sent away. A great many families do 
not care to take a wet-nurse from an asylum, as they are usually women of 
the lowest walks of life, and they prefer, therefore, to take a woman who 
has been married. For this purpose agencies, duly licensed, exist. These 
will supply wet-nurses, and usually take orders in advance ; thus a wet- 
nurse may be reserved. Such wet-nurses cost much more, and those from 
one special region — Iglau, in Mahren — receive from 20 to 50 florins monthly. 

The Empress took a wet-nurse from Iglau (a married woman), and 
the Princess of Bulgaria took a wet-nurse from Iglau for her last child. 
Not only Iglau, but the whole region, is renowned for its excellent quality 
of wet-nurses. The Bohemian and Mahren nurses have very good mammae. 
They seem to love the children entrusted to them. In America the wet- 
nurses are uneducated servants. 



106 NUTRITION. 

While it is a rule that a wet-nurse should be taken for an infant of the 
same age as that of her own, frequently wet-nursing of an infant at birth 
by a wet-nurse whose baby is three months old has not been followed by any 
bad results. 

In New York we are at a decided disadvantage regarding wet-nurses. 
As no licensed agents exist, a few people procure wet-nurses from superin- 
tendents and house physicians of hospitals where obstetrical work is done. 

The importance of properly supervising wet-nurses in the light of the 
danger of transmitting syphilis needs no further comment. The Health 
Department in every city should grant the use of their laboratories for a 




Fig. 36. — Pear-shaped Breasts, Best Adapted for Nursing. (Original.) 

careful blood examination of each and every wet-nurse. It is as important 
to prevent the transmission of syphilis to a child as it is to give an im- 
munizing dose of antitoxin to prevent diphtheria. 

Being positive that the blood of the wet-nurse is not diseased, our 
next examination should be of the milk. A wet-nurse whose milk contains 
colostrum corpuscles should be rejected until the colostrum corpuscles have 
disappeared. The chemical examination of the milk should be made to 
ascertain the percentage of fat. Milk that contains more than 2 per cent, 
of fat should not be used. If the wet-nurse selected has an exceptionally 
large quantity of milk and is otherwise healthy, then the milk, if it contains 
too much fat, may be pumped off with a breast-pump and diluted with 
water, and so fed from a nursing bottle. 

It is a pity that we have no municipal control for what the writer 
considers one of the most valuable adjuncts to our infant-feeding, and in 



WEANING AND FEEDING FROM ONE YEAR TO FIFTEEN MONTHS. 107 

the same manner such control would regulate the supply to such unlimited 
number that modern arrogance on the part of the wet-nurse would probably 
disappear. 

The prices paid in New York are from $40 to $50 per month and board, 
and this price prohibits many an infant from securing the benefits of 
Nature's food. Let us hope for municipal regulation. 

Weaning and Feeding from One Year to Fifteen Months. 

When the teeth appear, weaning must be considered. If the nursing 
mother becomes pregnant weaning is imperative. 

The condition of the infant, its sleep, its stool and its weight are fac- 
tors that should influence the decision to wean. In some infants gradual 
weaning may be attempted, but in most infants successful weaning can best 
be accomplished by the absolute cessation of the breast. 

If the infant has not gained in weight, puts its fingers into its mouth, 
cries or whines after the breast feeding, and if the stools are thin and watery, 
then weaning is imperative. Such an infant will gain in weight and be 
better satisfied when given the following formula : — 

Whole milk 6 ounces 

Sterile water 2 ounces 

Malt sugar 1 teaspoonful 

Heat until the steam rises. Feed the above quantity every four hours. 

An infant nine months old may have a saucer of well-steamed (two 
hours) farina, hominy or Pettijohn, one-half hour before the second feeding 
each morning. The juice of one-half pound of broiled steak can be secured 
with a meat press and fed every other day at noon. A saucer of rice 
steamed in equal parts of milk and water, or half a cup of junket, may be 
fed before the 6 p.m. bottle. When constipation exists the juice of an 
orange or the pulp of stewed prunes pressed through a strainer may be given 
one hour before a milk feeding. Crackers, zwieback, and biscuits may be 
given, but all floury foods tend to constipate. In the bottle 8 ounces of 
whole milk steamed about five minutes may be given. The addition of one 
teaspoonful of Loefflund's malt soup to each bottle will offset constipation. 
If a tendency to loose bowels exists, the cream should be skimmed from the 
milk, and this fat-free milk boiled. The addition of limewater is indicated 
where looseness exists. 

6.00 A. M . Breast 

9.30 A. M Cereal 

10.00 A. M. . . Bottle 

2.00 P. M. . . Breast 

5.30 P. M Cereal or junket 

6.00 P. M Bottle 

10.00 P. M. Breast 



108 



NUTRITION. 



Weight and Development. 

When a child develops normally, it gains in weight. Breast-fed 
infants, as a rule, gain more than bottle-fed infants. The progress of an 
infant can be watched by a comparison with its weight. The moment a 
child's weight is stationary, the reason for the same should be ascertained. 




Fig. 37. — The Chatillon Scale is a very convenient basket scale. It is very 
useful in the nursery. 



If the baby is breast-fed the milk of the nursing mother should be sent to 
a chemist for examination. (The details have already been described in 
the article on "Breast-milk.") 

Disturbances of the mother interfering with proper lactation are at 
once evident in her milk. Such disturbances are: (a) menstruation; (b) 
general anaemia; (c) tuberculosis, and (d) pregnancy will frequently alter 
the percentage of the ingredients of milk so that a child will not receive 
sufficient nutrition. 

The first evidence of such malnutrition will be seen on the scales. 
The child will not gain in weight, and frequently it will lose weight. 



WEIGHT IN BREAST-FEEDING. 109 

How Much Should an Infant Weigh?— The average weight at birth 
is 7 pounds. Some children weigh considerably more and some less. A 
child should double its weight at the end of five months, and treble its 
weight at the end of the first year. It must not be supposed that because 
a child weighs less than this amount it may not be healthy. All fac- 
tors should be taken into consideration and a child should be carefully 
examined to determine whether or no it is normal. Very many babies are 
up to the normal in weight, and still show marked rachitis. The very fat 
and flabby baby — usually supposed to be extremely healthy by the laity- 
is the one in whom physicians most frequently meet with constitutional 
disorders. Thus, too much stress should not be put on the scales, for we 
know that they have their limitations. In the beginning, or during the first 
and second months, a normal infant gains about 6 to 8 ounces a week. Dur- 
ing the third month a child gains from 4 to 6 ounces per week, and after the 
third month from 3 to 4 ounces per week. 

Weighing Immediately After Nursing to Determine the Quantity of 
Milk an Infant has Taken. — When scanty milk supply is suspected in either 
the nursing mother or in a wet-nurse, then we can, in some instances, resort 
to weighing immediately after the baby has nursed. It is understood that 
the child must be weighed both immediately before nursing and then imme- 
diately after nursing. The difference in weight is the amount of milk 
swallowed. 

While this may serve in some cases, the author has not found it very 
practical, and cannot recommend it, excepting in rare instances. 

It is well known that an infant whose stomach is filled requires rest 
after nursing, and the less it is handled the less is the chance for expelling 
its food. Thus, my advice is not to handle or fumble with a child after 
nursing, but rather aid Nature in resting an infant than provoke vomiting 
by unnecessary handling. 



Table No. 17. 
Table Shoioing the Gain of a Healthy Infant Fed at the Breast. 

Normal weight at birth, 7 Gain at the end of the first 

lb. week, none. 

Weight when 2 weeks old, 7 Gain at the end of 2 weeks, 6 

lb. 6 oz. oz. 

Weight when 3 weeks old, 7 Gain at the end of 3 weeks, 8 

lb. 14 oz. oz. 

Weight when 4 weeks old, 8 Gain at the end of 4 weeks, 8 

lb. C oz. oz. 



110 



NUTRITION. 



The following cases will serve to illustrate the weight of infants with 
various methods of feeding — (a) breast-feeding, (&) home modification, 
(c) laboratory feeding : — 



19 
IS 

n 
is 

I 

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Birth 8 
7 



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Fig. 38. (Original.; 



Baby Robert M. F. Normal at birth. Was wet-nursed. Gain, first month, 
2^4 pounds; second month, li^i G pounds; third month, 1% pounds; fourth month, 
IVs pounds. Stools were normal. Had gastric disturbances and symptoms of 
colic while the wet-nurse menstruated. When the child was about seven months 
old the chemical analysis of the breast-milk showed a deficiency of fat and quite a 
high percentage of proteins. The milk supply gradually gave out and it was 
necessary to wean the child. 



WEIGHT IN ARTIFICIAL FEEDING. 



111 




Fig. 39. (Original.) 

liaby J. S. Born prematurely. Weighed 5 pounds 14 ounces at birth. Was 
bottle-fed. Vomited; had dyspeptic symptoms, such as cheesy stools, restlessness 
at night, crying continually, and excoriated anus. When one month old the weight, 
including shirt and diaper, was 6 pounds. A wet-nurse was procured. The child 
gained 1 pound during the first week, and an average of 10 ounces a week thereafter. 
Dyspeptic symptoms disappeared; stools became normal. The child was not seen for 
six months, and is a perfectly healthy baby today. 



h 






n 

t 

'i 



^ 



Fig. 40. (Original.) 

From baby fed on Eskay's food since end of third week. General condition 
satisfactory, although somewhat constipated. 



112 



NUTRITION. 



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Fig. 41. (Original.) 

Baby A. Case of chronic dyspepsia. Child four months old. Weighed 8 pounds 
15 ounces. Gained 13 ounces the first week of treatment; G ounces the second week; 
7, 12, 9 ounces respectively during each of the succeeding weeks. 






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Fig. 42. (Original.) 

Baby D. S. Weighed 5 pounds at birth. . Was fed at Walker-Gordon Labora- 
tory since six weeks old. Lost weight during an attack of measles when twenty-six 



WEIGHT IN PERCENTAGE FEEDING. 113 

weeks old. Did not gain one ounce from the thirty-eighth to the forty-second week, 
although received a formula of: — 

Fat 4.00 

Sugar G.50 

Protein 2.50 

Six feedings, of seven ounces each. 

I ordered the following home modification : — 

Raw milk 6 ounces 

Barley water 2 ounces 

Mellin's food 2 teaspoonfuls 

Feed every three hours. 

In addition thereto I ordered one ounce of steak juice or one ounce of 
orange juice, daily, one hour before feeding. 

I also gave the white of one raw egg with the evening feeding. The 
food agreed very well and child gained in weight as I gradually added more 
milk and reduced the quantity of barley water. 

A growing child needs far more food than its weight alone would 
indicate, for its income must exceed its expenditure so that it may grow. 
An infant for the first seven months or first one-half year of life should 
have nothing but milk. Up to this age vegetable food is unsuited to it; 
it is purely a carnivorous animal. 

The diet of the infant is nearly twice as rich in proteins, half as rich 
again in fats, and a little more than half as rich in carbohydrates as that 
of the adult. It is, therefore, in a physiologic sense a luxurious diet. 

The strain of growth falls heavier upon the more precious proteins than 
upon the more cheap and common carbohydrates. 1 

When children do not gain in weight, the quantity of sugar should 
be increased. This should be done continuously and with due consideration 
for the other ingredients. 

The constructive ingredient in an infant's food is the proteins. We 
must, therefore, consider this element when an infant's weight is stationary. 

Individual conditions must be considered, and chronic disorders elim- 
inated, e.g., dyspeptic conditions or tuberculosis, before arriving at a. diag- 
nosis of what really causes an infant's loss in weight. 



'Stewart's Physiology," p. 412, 1897. 



CHAPTER II. 

COWS' MILK. 

Hammersten 1 gives the following analysis of cows' milk in a thou- 
sand parts as follows : — 

Water . . . 874.2 

Solids 125.8 

Fat 36.5 

Sugar 48.1 

Salt 7.1 

Protein (casein, 28.8; albumin, 5.3) 34.1 

A. Baginsky 2 gives the following analysis of coavs' milk, made at the 
Kaiser and Kaiserin Friedrich Hospital, Berlin : — 

Water '.-. 87.60 

Solids 12.38 

In one hundred parts. 

The solids consist of : — 

Casein and albumin 3.65 

Butter :. 3.11 

Milk-sugar 4.54 

Inorganic salts 1.08 

Besides large amounts of potassium and potassium salts and small 
quantities of iron. 

Composition, Variation, and Production. — Milk of all animals, roughly 
speaking, is composed of the same ingredients, hut an analysis of milk is 
apt to be very misleading, as it does not show the physical condition of the 
milk, which is the important thing to know, from the physician's standpoint. 

The general ingredients of milk are fat, sugar, albumin, casein, salts, 
and water. These ingredients vary in quantity from day to day, and from 
milking to milking. An average analysis of a woman's milk does not show 
what an infant is getting, by any means, for the composition of the milk 
depends upon the food, the health of the mother, and the frequency of 
nursing. 

The Breed of a Cow. — Some breeds yield quantity; others quality. 
Holsteins produce the most milk; Alderneys and Jerseys yield the most 
fat; Shorthorns give the most casein and sugar. The average capacity of 
a cow's udder is about 5 pints, and the annual yield of milk is about 600 
gallons. 



1 "Physiological Chemistry." 

2 "Diseases of Children," 1899, page 32. 



(114) 



COWS' MILK. H5 

Time and Stage of Milking". — Cows are usually milked twice a day, 
the morning milk usually being larger in quantity and poorer in quality. 
The milk which is first drawn is known as the fore-milk, and contains very 
much less fat than that last drawn, known as the strippings. This is due 
to a partial creaming taking place -in the udders. Dishonest dealers have 
often taken advantage of this fact in adulteration cases to have the cows 
partially milked in the presence of ignorant witnesses, the resulting milk 
consisting largely of the fore-milk. 

Age of Cows. — Young cows give less milk, while cows from four to 
seven years old give the richest milk, and less milk is given with the first 
calf. They give the largest yield, according to Fleishmann, after the fifth 
until the seventh calf; after the fourteenth calf they yield, as a rule, no 
more milk. The poorest milk is yielded during the spring and early sum- 
mer ; the richest during the autumn and early winter. If cows are worried 
or driven about, the quality and quantity of the milk are reduced. If they 
are kept warm and well fed, both quantity and quality are naturally in- 
creased. 

According to Eotch, the Durham, or Slwrtliorn, represents the best type 
of cow for this purpose. She has great constitutional vigor, great capacity 
for food, a perfect digestion, and, most important of all, a quiet tempera- 
ment. The analysis of her milk is as follows : — 

Per cent. 

Fat 4.04 

Sugar 4.34 

Proteins 4.17 

Mineral matter 0.73 

Total solids 13.2S 

Water 8G.72 



100.00 



The Devon is another breed of cow having the same characteristics as 
the Durham. The3 T are gentle and vigorous, and yield a large quantity of 
rich milk, the analysis of which is as follows : — 

Per cent. 

Fat : 4.09 

Sugar 4.32 

Proteins . 4.04 

Mineral matter 0.76 

Total solids . . . 13.21 

Water 86.79 



100.00 



HQ NUTRITION. 

The Ayrshire, another type, while representing strength, is somewhat 
nervous, and while not as hardy as the Durham, they are free from disease 
and yield a large quantity of milk, the analysis of which is as follows: — 

Per cent. 

Fat 3.89 

Sugar 4.41 

Proteins 4.01 

Mineral matter 0.73 

Total solids 13.04 

Water 86.96 



100.00 



The TIolstein-Friesian, commonly called Ilolstcin, represents the most 
perfect type of cow. She yields a large quantity of milk, though light in 
its total solids. The following is the analysis : — 

Per cent. 

Fat 2.88 

Sugar 4.33 

Proteins . 3.99 

Mineral matter 0.74 

Total solids 11.94 

Water : . . 88.06 



100.00 



Some of the marks which distinguish the breeds of cows best adapted 
for infant feeding are : — 

1. Constitutional vigor. 

2. Adaptability to acclimatization. 

3. Notable ability to raise their young. 

4. Freedom from intense inbreeding. 

5. A distinctly emulsified fat in the milk. 

6. A preponderance in the fats of the fixed glycerides over the vola- 
tile glycerides. 

The volatile glycerides do not exist in the mammae, but are formed 
in the milk soon after milking. In some breeds, as in those of the Channel 
Islands, this change occurs more quickly than in others. Such breeds, as the 
Jersey, Guernsey, and any others in which intense inbreeding has been car- 
ried on, and in which acclimatization has not been perfected, should not 
be used for infants and young children. These breeds, of course, do not 
represent all of those available for substitute feeding, for we may mention 
many others equally good each in its country. For example, the Kerry, 
of Ireland ; the Bed Polled, of England ; the Dutch Belted, and the Flem- 
ish; also, the Flamande and the Cotentine, of France; the Norman breed, 



COWS' MILK. 117 

of Normandy ; besides the Sirmenthal, sometimes called Bernese, of Switzer- 
land; together with the Chianina, of Italy, and the Allgauer, of Germany. 
The native cow of this country, the a Eed Cow," through many generations 
of neg'ect and exposure in winter, has undoubtedly acquired an impaired 
digestion, and does not respond readily to appropriate changes of food. 

Care of the Cow. — Knowing the cow to be a sensitive animal, she 
should be carefully guarded from useless excitement. She should be care- 
fully groomed by cleaning and washing, and the parts should be thoroughly 
dried. The barn should have plenty of fresh air, and the sunlight should be 
admitted. There should be plenty of room for exercise. In the stalls the 
cow should have perfect freedom for her head and limbs. The food a cow 
receives should be wholesome and varied. She should never be fed with the 
by-products of brewery or glucose factories. The food best adapted for the 
cow is hay, wheat, bran, ground oats, and cornmeal. In winter sugar beets 
and carrots may be added. Much care is needed to graduate the change from 
green foods to dry, as disturbance of the equilibrium of the mammary 
gland is followed by injurious effects to the consumer. We should strive 
to give a cow green clover, green corn, green oats, and meadow grass. Poi- 
sonous weeds must be guarded against. Not infrequently we read of gastro- 
enteric conditions in children, which are traceable to poisonous weeds. Pure 
water in large quantities must always be at hand. A cow is best adapted 
for the production of milk between her third and ninth years. The milk 
of a cow is not adapted for infant feeding until it is free from colostrum 
corpuscles. It should not be used in the advanced stage of pregnancy. 

Tuberculin Test. — Every dairy now resorts to proph} T lactic measures; 
hence, none should be employed that has not been subjected to the tuber- 
culin test. Besides this, each cow should be examined by a skilled veteri- 
narian regarding her physical condition. 

Care of the Mill'. — The vital point consists in excluding germs and 
barn filth. The Milk Commission of New York has tentatively fixed upon 
a maximum of 30,000 germs of all kinds per cubic centimeter of milk. A 
cubic centimeter is about one-half a teaspoonful, and a quart of milk con- 
tains about 900 cubic centimeters, so the total number of germs in a quart 
must be less than 27,000,000. 

This standard must not be exceeded in order to obtain the endorsement 
of the Commission, and must be attained solely by measures directed toward 
scrupulous cleanliness, proper cooling, and prompt delivery. 

Furthermore, the milk certified by the Commission must contain not- 
less than 4 per cent, of butter fat, on the average, and have all other 
characteristics of pure, wholesome milk. 

In order that dealers who incur the. expense and take the precautions 
necessary to furnish a truly clean and wholesome milk may have some suit- 
able means of bringing these facts before the public, the Commission offers 



118 NUTRITION. 

them the right to use caps on their milk jars stamped with the words: 
"Certified by the Commission of the Medical Society of the County of New 
York/' 

Eowland GL Freeman, answering an inquiry of mine concerning the pos- 
sibility of procuring milk free from germs in the dairy, says : "By means of 
special methods it has been found possible in some cases to obtain milk 
with only 10 bacteria per cubic centimeter. These methods are, however, 
not practicable for a large commercial supply. When the conditions at the 
dairy are known to be good a bacterial content averaging less than 5000 
per cubic centimeter has seemed to me satisfactory, while a bacterial content 
averaging less than 10,000 is fairly good." 

Thus it appears, that with excellent care, as described in the handling 
of milk, with modern hygiene, practically sterile milk can be procured for 
infant feeding. 

Certified Milk in New York. 

The dairy rules of the United States Department of Agriculture de- 
scribe in detail the caring and feeding of cattle. It was decided that the 
acidity of milk should not be higher than 0.2 per cent., and that the num- 
ber of bacteria should not be more than 30,000 per cubic centimeter. 

The Kockef eller Institute for Medical Eesearch inaugurated, a periodical 
inspection of the dairies and milk of the dealers who were willing to co- 
operate to secure a clean, fresh milk. 

It was observed that the milk from a cow milked in a dirty barn showed 
120,000 bacteria to the cubic centimeter, while another cow of the same 
herd milked in a pasture gave milk with only 26,000. A cow standing near 
a pile of dry feed had 1,000,000 bacteria per cubic centimeter, while the 
milk of other cows had a low bacterial count. Dirty cows gave a much 
higher count of bacteria than clean ones. Clean cows in a herd gave a count 
of 2000 as against 90,000 in the milk of the dirty cows. The milker was 
frequently found to be dirty, and the milk from some milkers always gave 
a high bacterial count. With the utensils it was sometimes difficult to find 
which factor was at fault. The ordinary strainer was, however, a prolific 
source of bacteria. 

With a sterile pail and a sterilized, cotton or cheese-cloth strainer the 
bacteria would fall in numbers. Aeration by requiring more complicated 
apparatus increased the danger of contamination. This was particularly 
so if aeration was carried out in a dirty barn or without regard to strict 
(cleanliness. 

The process of rapid cooling is one of the most important factors in 
the production of uncontaminated milk. The cooling of milk in springs 
is seldom sufficient, as the temperature of water in summer was found to 
vary from 45° F. to 70° F., whereas the milk should be brought below 45° F. 



THE ADULTERATION OF MILK. 119 

to insure few bacteria. Ice is absolutely necessary to the farmer who 
handles milk. W. H. Park (Yale Medical Journal) says, as to the number 
of bacteria in the city milk : "From an examination of nearly 1000 speci- 
mens there is no question about the enormous number of bacteria present in 
the city milk. Now as to the harm-fulness of this milk : The group of chil- 
dren under 1 year, on heated milk, received from decent farms, running 
before heating from 1,000,000 to 5,000,000 bacteria per cubic centimeter, 
did not, so far as we could see, suffer any serious harm from the bacterial 
products in the milk. During the summer these children had, off and on, 
intestinal disorders, but not much more than those in the same section of 
the city receiving milk from the very best possible dairies around New York. 
The children on pasteurized milk showed some very interesting results. 

"There were very .few bacteria in this milk when first received — any- 
where from 10,000 to 20,000; but on the second day they had so increased 
as to be from 10,000,000 to 30,000,000. In some cases where the 
second day milk was given there was immediate vomiting, followed by 
diarrhoea. 

"In the asylums, where the children were from 3 to 13 years of age, 
we found no trouble from the milk during the summer months, although 
in some cases it ran as high as 100,000,000 bacteria per cubic centimeter. 

"The reasons for the enormous development of bacteria in the milk were 
insufficient cleanliness in getting the milk and very faulty cooling arrange- 
ments. The farmers mostly put their milk in springs; as the summer 
advances the water gets higher in temperature until it reaches about 60° F. 
Some farmers hardly cool their milk at all. 

"The author has seen milk shipped in cans standing in a car where 
the temperature was 90° F., and left there without any ice for seven hours. 
The City Health Board has passed a rule that all milk shall be at a 
temperature of 50° F., or under, when it reaches New York City." 

The Adulteration of Milk. 

Formaldehyde in Milk. — The adulteration of milk by the use of for- 
maldehyde is becoming more common than is generally suspected. For a 
time its use was a "trade secret," but it has been so thoroughly advertised 
that every obscure individual who has a milk route is now familiar with the 
preservative qualities of formaldehyde. In our large cities the health officers 
are on the watch, and hence in these its use is being curtailed, but in the 
smaller towns and villages the people have not this protection. It would 
be well, therefore, for physicians to guard against this and keep it in mind 
when mysterious illness develops in milk-users. They should also be pre- 
pared to make an analysis of milk at any time as to its freedom from the 
drug. This is a simple procedure, and yet one that requires considerable 



X20 - NUTRITION. 

technical skill in the use of some of the tests. The Lancet-Clinic gives the 
various methods for testing formaldehyde as laid down by Herman Harms, 
some of which are quite simple : — 

Rimini Test. — (A) : Phenyl-hydrazine muriate, 0.5 gram; distilled 
water, 100 cubic centimeters; dissolve. (B) : Sodium nitroprusside, 0.5 
gram; distilled water, 30 cubic centimeters; dissolve. (O) Soda, TJ. S. P., 
15 grams; distilled water, 60 cubic centimeters; dissolve. To 15 cubic 
centimeters of the suspected milk in a test-tube add 10 drops of A, mix 
and add 3 drops of B; mix and let 5 drops of G run in slowly on the side 
of the test-tube. In the presence of formaldehyde a blue color is instantly 
produced, changing, on standing, to red. On adding to the mixture of 
milk and solution A, 2 drops of ferric chloride solution, and then about 2 
cubic centimeters of concentrated hydrochloric acid, a red color is pro- 
duced, which later changes to orange-yellow. In sour milk the above-men- 
tioned blue is supplanted by green. The Eimini test is easily applied, and 
readily detects formaldehyde when present to the extent even of 1 part 
in 25,000 or 30,000. 

PMoroglucin Test. — Dissolve 1 gram of phloroglucin in 100 cubic 
centimeters of distilled water. Put 10 cubic centimeters of the suspected 
milk in a test-tube and add 5 cubic centimeters of the phloroglucin solu- 
tion; shake and add 1 cubic centimeter of solution of potassa (U. S. P.). 
If formaldehyde is present, a red color is developed at once, fading usu- 
ally within five or ten minutes; hence the color must be observed at once. 
One part in 20,000 gives a decided reaction. 

Helmer's Test. — To 15 cubic centimeters of concentrated sulphuric 
acid in a test-tube add 1 or 2 drops of ferric chloride test solution (U. S. P.) 
and mix. Then pour upon this, in such manner as not to mix the layers, 
the suspected milk. A violet color indicates the presence of formaldehyde. 
In the case of cream dilute the cream with an equal volume of water, and 
then apply the test as above described. The violet color is sometimes pro- 
duced at once, but oftener not for five or ten minutes, and sometimes not 
for an hour or so, depending on the amount of formaldehyde present. By 
this test 1 part in 10,000 or 15,000 is readily detected. 

Liebermann Phenol Test. — In the presence of small traces of for- 
maldehyde, distill off from the milk a few cubic centimeters, and add to 
this 1 drop of very dilute aqueous phenol solution. Then pour this mix- 
ture slowly upon concentrated sulphuric acid in a test-tube solution so as 
to form a layer. A bright crimson color appears at the zone of contact. 
This is easily seen in as little as 1 part in 200,000, and in greater propor- 
tion in 1 to 100,000. There is a milky zone above the red color, and, if 
more concentrated, there will be a whitish or pinkish precipitate. Some- 
times the zone will appear in about one hour, one-tenth of an inch below 
the line of contact. 



MILK PRESERVATIVES. 



121 




122 NUTRITION. 

Hydrochloric Test. — Fifteen or 20 cubic centimeters of suspected milk, 
together with 2 or 3 cubic centimeters of strong hydrochloric acid, are 
boiled for a few minutes in a test-tube. A red coloration indicates for- 
maldehyde. Other tests are known, but they are more complicated and 
require apparatus or reagents not kept by the average pharmacist. The 
above tests are all simple in their application and afford a ready means of 
detecting formaldehyde in milk and cream. 

The Eimini test is highly recommendable. The reaction in sweet milk 
appears rapidly and with certainty. Hehner's test, as well as the phloro- 
glucin and phenol tests, are very reliable and are all extremely sensitive. 
The hydrochloric acid test is very simple, but is not to be depended on; it 
may show formaldehyde in most instances; however, cases have come under 
our observation when it has utterly failed to show the reaction, probably 
because of the milk having undergone some unknown changes. The Lie- 
bermann test is simple, delicate, and shows formaldehyde very readily. 

As corroborative evidence, it is well, after the -tests are finished, to 
let the suspected milk or cream stand in a warm place for twenty-four 
hours. A pure sample will invariably turn sour and separate. A sample 
which has been "doctored" with formaldehyde, however, will show, at the 
end of twenty-four hours, but a very slight separation, if indeed any at 
all, and will have but a slight odor. 

It is desirable that all test solutions be freshly prepared, especially the 
nitroprusside of sodium solution in the Eimini test, and that the suspected 
sample be as fresh as possible. Sour samples are difficult to test, and may 
yield variable results, because in these formaldehyde has been oxidized, and 
is no longer present as formaldehyde. In carrying out the tests for for- 
maldehyde it is advisable to work the suspected sample and the one known 
to be pure side by side. Finally, do not expose your tests or have your milk 
placed where a bottle of formaldehyde is being opened, for the vapor is very 
penetrating, and you thus may be easily led to misleading results. When 
formaldehyde has been found to be present by at least three of the afore- 
mentioned tests, it may be considered that its presence has been shown. 

Tuberculous Infection Through Milk. 

The question of tuberculous infection by ingestion of milk is answered 
in the negative by N. Aspe (Rev. d. Med. y Cir. Prac, Nov. 21, 1901). If 
the tubercle bacillus reaches the cow's udder, it must necessarily be carried 
thither by the blood. The bacillus has yet to be found in the blood; but, 
supposing its presence there, we are taught to believe that every gland in 
the body, by its selective power, takes from the blood only those elements 
which are necessary to the elaboration of its peculiar products. This would 
seem to dispose of the possibility of infection of the milk before it leaves 



TUBERCLE BACILLI IN MILK. 123 

the cow's body, unless the elective faculty, attributed to other glands, be 
denied to the mammary. Granting this possibility, if we recall that in the 
production of experimental infections by subcutaneous inoculation the first 
organs to be affected are the lymphatics, it is natural to suppose that the 
first and invariable effect of the ingestion of tuberculous milk would be the 
development of tabes mesenterica, yet primary tabes is comparatively rare. 
The author of this paper further raises the question of identity between the 
human and bovine tubercle bacillus, and quotes experiments in inoculation 
of cows with cultures from human tuberculous products with negative results 
in the nineteen animals experimented upon, whereas animals injected with 
the bovine form quickly succumbed, and autopsy showed tuberculous lesions. 

The Influence cf High. Temperature on Tubercle Bacilli in Milk. — 
Barthel and Stenstroni (Centralblt. /. Bdkt., October 8, 1901), in reviewing 
recorded experiments on the sterilization of tuberculous milk, remark on the 
very variable results obtained by different observers. Bang has stated that 
heating tuberculous milk to 80° C. is not sufficient to kill the bacilli, but 
that a temperature of 85° C. is sufficient for the purpose. Forster has found 
70° C. for five to ten minutes capable of killing the organisms; de Man, 70° 
C. for ten minutes, and 80° C. for five minutes. Galtier has shown that milk 
submitted to 70°, 75°, 80°, and 85° C. for six minutes is still capable of 
conveying infection, and others have had similar results. Barthel and Stens- 
troni have conducted experiments which go to show that the chemical reac- 
tion of the milk has much to do with the facility with which it is sterilized. 
The material was obtained from a cow with an udder in an advanced state of 
tuberculosis. Guinea-pigs were used to test the results, and the effect of 
G5°, 70°, 75°, and 80° C. was studied. The results were positive in all 
cases; that is to say, a temperature of 80° C. for ten minutes, a temperature 
of 75° C. for fifteen minutes, 70° C. for fifteen minutes, and 65°' C. for 
twenty minutes were all incapable of sterilizing the milk. These results 
the authors interpret as follows : Storch has shown that the chemical 
changes in milk are the more marked the more advanced the disease of the 
udder, and that the reaction becomes more and more markedly alkaline. 
On the other hand, it has long been known that it is more difficult to sterilize 
an alkaline than a neutral, and a neutral than an acid fluid. The specimen 
with which they worked was strongly alkaline, and to this they ascribe the 
difficulties in its sterilization. Variations in chemical reaction explain, in 
their opinion, the variations in the results obtained by other investigators. 

The Tuberculin Test of Pure-bred Cattle.— Mr. D. E. Salmon, D. V. M., 
Chief of the Bureau of Animal Industry of the United States Department 
of Agriculture, has recently issued a pamphlet in which he demonstrates the 
necessity of guarding against the importation of disease by means of cattle, 
and upholds the present regulations to prevent such occurrences as proper 
and consistent. The chief danger to cattle arises from the prevalence of 



124 



NUTRITION. 



tuberculosis, which disease affects herds more widely and more disastrously 
than any other. 

Even if the point urged by Professor Koch at the British Congress on 
Tuberculosis be granted, and it is allowed that the spread of tuberculosis by 
milk and meat is to be feared but to a slight extent, the fact must still be 
borne in mind that tuberculosis, in itself, is a decimating factor among 
cattle of immense importance. 

Mr. Salmon shows that the United States has a very large export trade 
in cattle, and one that is continually increasing. He further points out that 
rigid restrictions are in force in many countries in the world to prevent 
tuberculous beasts from gaining an entrance into those territories; conse- 
quent^, if we wish our cattle to enter those markets, they must not only be 
free from tuberculosis when they leave the farm, but also when they arrive 
in a foreign country. To effect this object, every effort must be put forth 
to keep out tuberculous cattle from this country, for a few thus diseased will 
quickly spread contagion. 

The argument is therefore advanced that the tuberculin test as now 
adopted must be strictly enforced to guard against such a result. The con- 
tention is likewise made that the pure-bred cattle mainly imported from 
Great Britain are the chief menace in this respect, and that, if the tuber- 
culin test were not strictly adhered to, the blue-blooded immigrants from 
the United Kingdom would disseminate the germs of tuberculosis among 
cattle from one end of the country to the other. 

Tubercle Bacilli Disseminated by Cows in Coughing, as a Possible 
Source of Contagion. — The general belief at the present time that the means 
by which tuberculosis is chiefly disseminated, by the inhalation of dried 
tuberculosis sputum which becomes pulverized and is carried about by cur- 
rents of air, or put into motion in other ways, has been strongly substan- 
tiated by numerous experiments. Fliigge, however, is not in accord with 
these views, and is of the opinion that th'e spread of tuberculosis is due 
mainly to the inhalation of minute particles of sputum which the act of 
coughing thus ejects. He further holds that these particles' float in the 
air for a considerable period of time, and may be blown hither and thither 
by very slight currents. Klebs, in this country, has demonstrated the fact 
that, during the act of coughing, minute particles of sputum, often con- 
taining tubercle bacilli, are thrown out. At his instance, too, Curry, of 
Boston (Boston Medical and Surgical Journal, October, 1898, vol. cxxxix, 
No. 15), carried out a series of elaborate experiments with the object of 
thoroughly investigating the matter. 

Dr. Curry concluded from his experiments that, although there is a 
possible, and even a probable, danger from this source, Fliigge has greatly 
exaggerated this clanger. Dr. Mazyck, lecturer and demonstrator of bac- 
teriology, Veterinary Department, University of Pennsylvania, has been led 



TUBERCULOUS INFECTION THROUGH MILK. 125 

to undertake experiments to see if it were not possible that cows in the act 
of coughing would likewise expel small particles of tuberculous material 
rich in tubercle bacilli. The results of these studies were made the subject 
of a paper by Dr. Mazyck, which was read before the Pathological Society 
of Philadelphia on November 8, 1900. The belief is common that cows 
when coughing swallow all their sputum, and do not project it to any extent. 
Dr. Mazyck, by ingenious methods devised by himself, has disproved this 
theory, and has practically demonstrated that, in the act of coughing, cows, 
as well as men, atomize, so to speak, their sputum, and project it into the air 
in minute particles, which may float for some time. Inoculation of guinea- 
pigs with this secretion gave a considerable proportion of positive results. 
Dr. Mazyck came to the conclusion that the danger of infection by means 
of this atomized sputum, as far as mankind goes, is confined practically to 
those in constant contact with the animals, but for other animals in the 
same stable the infected animals must be considered a source of danger. 
The moral to be derived from the outcome of Dr. Mazyck's experiments 
would seem to be that when tuberculosis is diagnosed in a cow she should 
be isolated as far as is possible; at any rate, she should not be confined in 
a shed with healthy animals. 

Sterilization and Pasteurization vs. Tubercle-free Herds, etc. 1 — The 
comparative dependence upon sterilization or pasteurization and the insur- 
ance of absolute absence of tubercle in herds supplying milk are discussed 
by Hope, who thinks that, while raw milk is especially liable to contamina- 
tion, sterilization, valuable as it is, is, after all, only an expedient, and must 
not be put in such prominence that the importance of the other safeguards 
of absolute cleanliness of source and handling are neglected. Beyond any 
question, he says, the ultimate advantage lies in obtaining the milk from 
herds free from tuberculosis. A comparison is made with having water 
from a contaminated source and making it pure later by chemical processes 
or boiling it, and obtaining it in the first place from an uncontaminated 
source. He thinks it is quite possible to insure that the milk supply shall 
come from cows free from tuberculosis. 

The State Veterinarian of Pennsylvania, Dr. Pearson, thinks that not 
over 2 per cent, of the cattle of that State are tuberculous, and probably 
if a general test of all the cattle of the other States mentioned were made 
we should find a very much smaller proportion tuberculous than is indicated 
by this tabular statement. The explanation of the high percentages that 
have been given is found in the fact that it has been, for the most part, 
suspected herds which have been tested. Admitting that the greater part 
of these percentages are too high, we still have revealed a condition which 
is worthy of our serious consideration. 



*E. W. Hope (The Lancet) 



126 



NUTRITION. 



The classes of animals most affected are breeding animals and dairy 
stock. The beef cattle coming to our markets are still singularly free from 
tuberculosis. Of 4,841,166 cattle slaughtered in the year 1900 under Fed- 
eral inspection, but 5279, or 0.11 per cent., were sufficiently affected to cause 
the condemnation of any part of the carcass. Of 23,336,884 hogs similarly 
inspected, 5440 were sufficiently affected to cause condemnation of some part 
of the carcass. This is equal to 0.023 per cent., or slightly more than one- 
fifth the proportion found in beef cattle. It is scarcely necessary to add that 
there are certain lots of cattle and hogs encountered which are affected in 
much greater proportion than the general average just given. 

From a recent view by Drs. Eussell and Hastings, of the Wisconsin 
Agricultural Experiment Station, 1 of the tests of cattle for tuberculosis 
made in the United States, the following summary is presented : — 

Table No. 19. 



Vermont 

Massachusetts 

Massachusetts, entire herds 

Connecticut 

New York, 1894 . . . . 

New York, 1897-98 

Pennsylvania 

New Jersey 

Illinois, 1897-98 

Illinois, 1899 

Michigan 

Minnesota 

Iowa 

Wisconsin — 

Experiment Station tests: 

Suspected herds 

Non-suspected herds 

State Veterinarian's tests: 

Suspected herds 

Tests of local veterinarians under 
State Veterinarian on cattle in- 
tended for shipment to States 
requiring tuberculin certificate . 



Number 
Tested. 



60,000 
24,685 

4,093 

6,300 
947 

1,200 

34,000 

22,500 

929 

3,655 

3,430 
873 



323 
935 

588 



3,421 



Number 
Tuberculosis. 



2,390 

12,443 

1,080 

"*66 

163 

4,800 



560 



122 



115 

84 

191 



76 



Per cent. 
Tuberculosis 



3.9 
50.0 
26.4 
14.2 

6.9 
18.4 
14.1 
21.4 
12.0 
15.32 
13.0 
11.1 
13.8 



35.6 
9.0 

32.5 



2.2 



The following suggestions, adapted from the fifty dairy rules of the 
United States Department of Agriculture, are recommended for strict adop- 
tion in our dairies : — 

The Stable. — Keep dairy cattle in a room or building by themselves. 
It is preferable, when possible, to have no cellar below and no storage loft 
above. The stables should be well ventilated, lighted, and drained; should 
have tight floors and walls and plainly constructed. Store the manure under 
cover outside the cow stable, and remove it to a distance as often as prac- 



1 Bulletin No. 84, Wisconsin Agricultural Experiment Station, March, 1901. 



CARE OF THE MILK. 127 

ticable. Whitewash the stables once or twice a year; use land plaster in 
the manure gutters daily. Clean and thoroughly air the stable before milk- 
ing ; in hot weather sprinkle the floor. 

The Cows. — Have the herd examined at least twice a year by a skilled 
veterinarian. Promptly remove from the herd any animal suspected of 
being in bad health and reject her milk. Never add an animal to the herd 
until certain it is free from disease, especially tuberculosis. Do not allow 
the cows to be excited by hard driving, abuse, loud talking, or any unneces- 
sary disturbance. Feed liberally, and use only fresh, palatable food stuffs. 
Provide water in abundance, easy of access, and always pure. Do not allow 
any strongly flavored food, like garlic, cabbage, turnips, to be eaten except 
immediately after milking. Clean the entire body of the cow daily. If the 
hair in the region of the udder is not easily kept clean, it should be clipped. 
If the sides of the cow are plastered with dirt or manure, as is often the 
case, a certain amount is sure to fall into the pail of milk. This is where 
the trouble really begins, for this dirt and manure abound in bacteria which 
cause decomposition in milk, and thereby induce bowel disturbances. 

The Milk. — The milker should be clean in all respects. He should wash 
and dry his hands and clean his nails just before milking. After the hands 
have been washed, a little vaseline may be used on them, thereby preventing 
scales from the teat or fingers getting into the milk. The milker should 
wear clean, dry garments, used only when milking, and kept in a clean place 
at other times. Brush the udder and surrounding parts just before milking, 
and wipe them with a clean, damp cloth or sponge. Commence milking at 
the same hour every morning and evening, and milk quietly and thoroughly. 
Throw away (but not on the floor — better in the gutter) the first few streams 
from each teat. This first milk is watery and of little value, and during 
the intervals between milking, the bacteria from the air get into the cow's 
teats and grow with great rapidity. These bacteria cause early souring of the 
milk. If in any milking a part pf the milk is bloody or stringy or un- 
natural in appearance, the whole mass should be rejected. Milk with dry 
hands, or oiled as above; never allow the hands to come in contact with the 
milk. If any accident occurs by which the pail, full or partly full, of milk 
becomes dirty, do not try to remove this by straining, but reject all this 
milk and rinse the pail. 

Care of the Milk. — Eemove the milk of every cow from the dairy at 
once to a clean, dry room, where the air is pure and sweet. Do not allow 
cans to remain in stables while they are being filled. Strain the milk through 
a metal gauze and a flannel cloth, or layer of cotton, as soon as it is drawn. 
Aerate and cool the milk as soon as strained. The rapid aeration and cooling 
of milk are matters of great importance. Combined aerators and coolers, 
suitable for use with well water or ice water, can be had at any dairy supply 
house at a small cost. By using one of these, the cow odor, the animal heat, 



128 • NUTRITION. 

and much of the dirt can be removed from milk in a few minutes. The milk 
should be cooled to 45° F., if for shipment, or to G0° F., if for home use or 
delivery to a factory. Never mix fresh, warm milk with that which has 
been cooled. Do not allow the milk to freeze. When cans are hauled a dis- 
tance they should be full and carried in a spring wagon. In hot weather 
cover the cans, when moved in a wagon, with a clean, wet blanket or canvas. 
If milk is stored, it should be held in tanks of fresh, cold water, renewed 
daily, in a clean, cold, dry room. Clean all dairy utensils by first thoroughly 
rinsing them in warm water; then clean inside and out with a brush and 
hot water into which a cleansing material is dissolved ; then rinse, and lastly 
sterilize by boiling water or steam. Use pure water only. After cleaning, 
keep the utensils inverted in pure air and sun if possible, until wanted for 
use. Old cans, in which parts of the tin are worn off, or where there are 
seams and cracks, are impossible to keep clean, and should not be employed. 

Small Animals. — Cats and dogs must not be in the stables during the 
time of milking. The reason for this is that cats are peculiarly liable to 
transmit diphtheria; both cats and dogs have disgusting skin diseases which 
may be transmitted to children, and both animals also are apt to nose 
around and dirty the utensils. 

If precautions like the above are strictly carried out, the milk will be 
clean and remain fresh for a considerable length of time. The fresher the 
milk is, the better it will be for family use. The test for un cleanliness con- 
sists in an increase in the proportion of lactic acid generated in the milk, 
and in a large increase in the number of bacteria per cubic centimeter. 

The New York Senate passed a bill recently, forbidding sale of milk 
containing formaldehyde or salicylic acid, owing to their injurious effects on 
infants. 

Saw Milk. 

Monrad (Jahrbucli f. KinderheWkunde, No. 55, p. 61) describes a 
series of children fed with raw milk. These infants could not digest ster- 
ilized or boiled milk. Their condition improved when raw milk was sub- 
stituted. It was interesting to note that during the course of Monrad's 
investigations an infant received sterilized milk by mistake, and its former 
dyspeptic symptoms reappeared. 

Jensen found that new-born calves assimilated raw milk, but when 
boiled milk was given, they were subject to coli-enteritis. Such calves that 
recovered were atrophic. Milk, when subjected to prolonged sterilization, 
such as tyndalizing the milk, undergoes certain chemical changes. These 
are : — 

1. Nuclein and lecithin are rendered insoluble. 

2. Milk-sugar is completely changed. 

3. The coagulability of the casein is impaired. 

4. The fat globules are separated and rise to the surface of the milk. 



RAW MILK. 129 

5. By the influence of the chlorides on the casein peptones are formed 
in the milk. 

G. The milk is rendered unpalatable by this superheating. 

7. The albumin is rendered much less assimilable by prolonged heating. 

The increased number of cases -of rickets and Barlow's disease since the 
advent of sterilization does not speak well for this process. 

Certain factors should be noted : — 

1. That sterilization is intended to kill pathogenic bacteria in the 
milk. 

2. That not only are pathogenic bacteria destroyed, but also sapro- 
phyte.^ which certainly have some bearing on the digestive functions of an 
infant. 

We know that- the proteolytic bacteria are in the milk for certain 
reasons : — 

1. To coagulate the casein. 

2. To peptonize this coagulated casein. 

It is possible that by sterilizing milk and destroying these bacteria, we 
rob the milk of microbes necessary to perform certain aids in the digestive 
process. 

Such assistance in the digestion of milk may not be necessary in the 
robust and normal infant, but it is quite different when we are dealing with 
dyspeptic or atrophic infants. 

When infants thrive on sterilized milk, then it is a good plan to con- 
tinue the same; but if dyspeptic symptoms — vomiting and undigested, cheesy 
stools with colicky symptoms — show themselves, then such food should be 
discontinued. Such cases demand a radical change of diet, and it is here 
that an easily assimilated form of food is indicated. Such food is raw mill:. 

Scorbutic cases in which we continue giving sterilized milk will not be 
modified whether we add HC1, pepsin, or alkalies. The character of the 
food is at fault and a radical change must be made. For the treatment of 
atrophy nothing will supersede raw milk. Certain precautions must be taken 
in securing raw milk for infant feeding. 

The ideal cows' milk is clean, raw milk. By this is meant milk free 
from all possible contamination. Such milk should be obtained from a 
stable having all modern hygienic surroundings. If greater attention were 
bestowed on the condition of the cow, the cow's udder, the stable, the 
bucket, the hands of the milker, then less sterilization and pasteurization 
would be necessary. Let it be distinctly understood that certain chemical 
changes are brought about in milk when it is steamed, be it in the 
process of sterilization or pasteurization. Neither sterilization nor pasteur- 
ization adds to the digestibility of mill'. Indeed, chemical experience has 
demonstrated the fact that raw milk, sold in some places as certified milk, 
in the Walker-Gordon milk laboratories as guaranteed milk, is more easily 



130 



NUTRITION. 



assimilated. It is proven by the condition of the stools as well as the gas- 
tric digestion. 

Nature has given us a good example of how milk should be -fed to an 
infant. Breast-milk is certainly raw milk, and is served to the infant at 
the temperature of the body. Not only does boiling and steaming of milk 
produce chemical changes in the albuminoids, but it renders the process of 
digestion much more difficult, and thus it is that most infants taking boiled 
milk surfer with constipation. This is not so, however, in the case of infants 
fed on raw milk. 

When sterilized and pasteurized milks are found to disagree with chil- 
dren, raw milk may sometimes be easily assimilated. Thus it will be found 
that, while boiled milk, or sterilized or pasteurized milk, given either whole 
or with its proper dilution to suit the various ages, will provoke constipa- 
tion, by substituting raw milk for heated milk the same will be more easily 
assimilated. The author has frequently noted decided antiscorbutic prop- 
erties in fresh raw milk. In children with pronounced rickets, and even 
scurvy, the withdrawal of sterilized or other milk and the substituting of 
fresh raw milk will work surprising changes. 

Biedert 1 states that he has followed Escherich and Epstein, who rec- 
ommend giving full milk to children at birth. In France, Budin and H. 
de Eothschild, and more recently E. Schlesinger, in Germany, have given 
undiluted milk to both sick and well children as a substitute for breast- 
milk. Biedert claims to have seen good results in some instances, but 
cannot recommend whole milk, as a rule, for feeding children. Marfan, 
another advocate of pure-milk feeding, believes that milk should be diluted 
. until the fourth or fifth month, but later he advises pure-milk feeding. 
Schlesinger, of Breslau, while giving pure milk, gives a longer interval 
between the meals. That the greatest possible success is not achieved 
by this method in France can be judged by the statement of Marfan 
while discussing the subject of athrepsia. He says: "N'a jamais vu 
Vathrepsie confirmee se terminer favorablement." Thus it seems that even 
we have much better results than the French, for there are certainly a great 
many children who can and will digest a diluted milk, and thin milk-and- 
cream mixtures, as shown by their stool, their sleep, and their increase in 
weight. These same children with enfeebled digestive functions will in- 
variably show gastric disturbances — such as vomiting, colic, constipation, or 
diarrhoea, restlessness, sleeplessness — and will cry continually when given 
whole milk. So that whole-milk feeding is not assimilated during the early 
months of a child's life; besides they do not increase in weight. This 
method of feeding has been tried over and over again, and we are compelled 
to discontinue the heavier food, consisting of whole milk, and substitute a 
light food, consisting of diluted milk. 



Fourth Edition of Kinderernahrung, 1900, page 184. 



RAW MILK. • 131 

Fresh Raw Milk. — Just as the medical profession, and to some extent 
the laity, have become impressed with the idea that milk should be boiled 
before being used, to insure the destruction of the microbes which it contains, 
Dr. Freudenrich comes forward with a series of experiments, by which 
he claims to prove that raw milk possesses remarkable germicidal proper- 
ties. According to his experiments, the bacillus of cholera, when put 
into fresh cows' milk, dies in one hour, the bacillus of typhoid fever suc- 
cumbs at the end of twenty-four hours, while other germs die at the end 
of varying periods. 

Milk which has been exposed to a temperature of 131° F. loses its 
germicidal properties. Milk which is four or five days old is also devoid of 
microbe-killing power. 1 

Undiluted Milk as a Food for Infants. — Xotwithstanding tireless re- 
search and wonderful ingenuity, a perfect substitute to replace mother's 
milk as an article of food for the nourishment of infants yet remains to be 
discovered. This is greatly to be regretted, as the occasions are not rare on 
which mother's milk is not available, or it is desirable or even necessary 
to have recourse to such a substitute. The fact is that there is yet not a 
little to learn concerning the assimilative processes in children, and knowl- 
edge, particularly of a practical character, concerning food is not so exten- 
sive or so precise as it might be. As Iv. Oppenheimer points out in a recent 
communication, an article of food for the infant to serve as a perfect sub- 
stitute for mother's milk should be as useful as the latter in the nourish- 
ment both of healthy children and of those suffering from gastro-intestinal 
catarrh. These requirements, however, are not met by any of the large 
number of artificial foods that have been devised. For the purpose of estab- 
lishing the usefulness of undiluted cows' milk as judged by this standard, 
Oppenheimer made comparative observations in normal healthy children, 
in infants suffering from gastro-intestinal derangement, and in atrophic 
children. In almost all of the 11 cases of the first group the body weight 
exhibited a steady and uniform increase, while of 36 cases of the second 
group only 6 failed to do well, and of 12 cases exhibiting marked atrophy 
8 failed to do well. All of the foregoing cases were under observation for 
periods of more than four weeks. Of 33 additional cases under observation 
for a shorter period than four weeks, 20 thrived and 13 did not. 

The Dangers. — We naturally regard the dangers of having tubercle 
bacilli in the milk as one of the prime reasons for sterilizing the same. AVe 
should never employ the milk from one cow, but always from a mixed herd. 

The danger of transmitting tuberculosis is certainly very rare. Au- 
thentic cases have been reported from time to time in medical literature 



1 Bacteriological World. December, 1S91; Journal of the American Medical 
Association, February 27, 1892. 



132 NUTRITION. 

in which a supposed infection could be attributed to milk. R. Koch disputes 
the possibility of transmitting bovine tuberculosis to man. 

In a herd of cows which has undergone the proper veterinary inspection, 
the danger of overseeing tuberculosis of the udder is reduced to a minimum. 

Fat. 

While it is true that a new-born infant with a healthy stomach can 
tolerate a higher fat percentage than an infant with a weak stomach, great 
care must be exercised to avoid overtaxing the digestive functions, so that a 
stomach breakdown does not result. 

Fat Metabolism. — The proper amount of fat that an infant can digest 
at birth is between 1 and 2 per cent. After several weeks 2 per cent, will 
be digested. Nutritional disturbances such as regurgitation and vomiting 
of sour-smelling liquids will follow the feeding of more fat than the stom- 
ach can tolerate. Some infants will thrive on -2% per cent, of fat, while 
others demand 3 to 3% per cent, of fat when six months old. The stool 
of excessive fat-fed infants will contain round or lentil-shaped particles of 
fat. Clinical experience has demonstrated that vomiting, colic, and restless- 
ness results more often from excess of fat than from any other ingredient 
in the food. 

Research has demonstrated conclusively that fat favors nitrogen excre- 
tion. The higher the fat, the less nitrogen will be retained. High fats usu- 
ally lead to the development of soap stools. Of the total fat ingested it is 
estimated that 87 to 98 per cent, will be absorbed. 

When we have a disturbance of fat metabolism there results a relative 
acidosis. Usuki believes that the soap stool is caused by a disturbance of 
fat metabolism due to excessive fat absorption rather than to poor fat ab- 
sorption. Bahrdt's 1 conclusions are just the reverse. He regards the soap 
stool due to a smaller absorption of fatty acids, resulting from an increased 
peristalsis of the small intestine, which, with an increased excretion of 
alkali, results in the formation of the saponified stool. 

The urine of an excessive fat-fed infant contains an excess of ammonia. 
The condition called "acidosis" results. High fat feeding results in an 
excess of volatile acids in the stomach and intestines. If the text-books of 
ten and twenty years ago are consulted the reader will find that the high 
fats were generally advocated. Whole milk and cream or top milk were 
strongly recommended for general feeding methods. That this was a fal- 
lacy has now been demonstrated. Finkelstein believes that when the fat 
content of the food is high, the disturbance caused thereby lessens the 
tolerance for sugar. Fat disturbances can be made out independent of 
whether the sugar content is high or low. 



Balirdt, Jahrb. f. Kinderh., 1910, 249. 



FAT. 133 

Digestion of Fat. — The digestion of fat begins in the stomach and is 
continued in the intestine. This synthesis of the fatty acids in the fat is a 
function of the intestinal epithelium associated with the secretion of the 
pancreas and other intestinal glands. Regarding the absorption of fat, we 
must not suppose that all fat found in the faeces is unabsorbed fat from the 
food. Normally the stool contains from 1 to 10 per cent, of fat, besides free 
fatty acids and their combinations with saponified fats. Fat is not the most 
important item of nutrition, because fat may be replaced by a certain 
quantity of carbohydrate. Whether an infant could live entirely without 
fat and receive in its stead a given quantity of carbohydrate has never been 
proven. Theoretically it is possible. 

Bah cock's Milk Test. — In this country the so-called Babcock milk test, 
invented by Dr. 'S. M. Babcock, has been adopted in preference to other 
practical milk tests, in creameries and cheese factories as well as in milk 




Fig. 43. — Centrifugal Testing Machine, for Handpower. 

laboratories. The cause of the general adoption of this test is doubtless 
to be found in its simplicity, cheapness, and ease of manipulation. Briefly 
stated, the test is operated as follows: 17. G cubic centimeters of milk are 
measured into a special milk-test bottle, an equal quantity of commercial 
H 2 S0 4 (specific gravity, about 1.83) is added, and after mixing the two 
liquids the test bottle is placed in a centrifugal machine and whirled for 
four minutes; hot water is then added to the bottle to bring the fat into 
the graduated narrow neck of the bottle, and after a second whirling of one 
minute the per cent, of fat in the milk is read off from the scale of the 
test bottle. 

A determination of fat in milk by this method takes less than fifteen 
minutes, and when care is taken in sampling the milk the reading of the 
result is accurate to within one-tenth of 1 per cent. Babcock testers are 
now placed on the market by many manufacturers of dairy supplies and at 
a remarkably low price, thanks to sharp competition among the manufac- 
turers. The testers are either hand or power (steam or motor) machines 
and built to hold from two to thirty or more te?t bottles at a time. The 
number of revolutions at which they must be run ranges from 800 to 1200 
per minute, according to the diameter of the testers. 



134 



NUTRITION. 



The Determination of Fat. — The simplest method is by the cream gauge 
(Fig. 44). Although its results are only approximate, they are in most 
cases sufficiently accurate for clinical purposes. The tube is filled to the 
zero mark with freshly drawn milk, which stands at a room temperature for 
twenty-four hours, when the percentage of cream is read off. The ratio of 
cream to fat is approximately 5 to 3 ; thus, 5 per cent, cream represents 3 
per cent, fat, etc. 

Another rapid method is by Marchand's tube. - 
■Marchand's Test.— "Fust put into the tube five cubic centimeters of 
milk, up to the line M; then four or five drops of liquor sodse; shake; add 




n 



c£> 



F * 



Fig. 44.— Graduated Cream 
Gauge, 10X1%. 



Fig. 45. — Marchand's Tube. 



Fig. 46.— Feser's Lactoscope 



five cubic centimeters of ether, up to the line E. Cork, and shake fifteen 
or twenty times; add 90 per cent, alcohol, up to the line A. The tube is 
now tightly corked, shaken thoroughly, and placed upright in a tall bottle 
containing water at a temperature of 120° to 150° F. The fat separates 
and forms a distinct layer at the top, and after half an hour the amount is 
read off in degrees. By reference to the following table the exact percentage 

of fat is shown : — 

Table No. 20. 



Degrees, Marchand. 


Percentage of Fat. 


Degrees, Marchand 


Percentage of Fat. 


1 


1.49 


13 


4.29 


3 


1.96 


15 


4.75 


5 


2.42 


17 


5.22 


7 


2.89 


19 


5.68 


9 


3.36 


21 


6.14 


11 


3.82 







SUGAR. 13;, 

Each additional degree on the tube corresponds to 0.23 per cent, of fat. 
To insure accuracy the test should be repeated two or three times with the 
same specimen. 1 

Another test is made by the .use of Feser's lactoscope. (See Fig. 46.) 
The test is made as follows : Four cubic centimeters of milk are measured 
off in a pipet, put into a tube, and water slowly added, shaking from time to 
time until the black lines of the porcelain stem at A are clearly visible 




Fig. 47. — Cows' Milk, Showing Fat-globules, Magnified 330 Diameters. 

through the mixture of milk and water. The percentage of fat is then read 
off on the glass cylinder at the level of the water added; thus, if the water 
is to the mark 4, it indicates the presence of 4 per cent, of fat. This test 
is only applicable to cows' milk. 

Sugars and Carbohydrates. 

Each sugar has its specific ferment in the intestine. Maltose has mal- 
tase, lactose has lactase, and cane sugar has invertin. These sugars are all 
acted upon in the mouth by the ptyalin of the saliva. They are further 
acted upon by the diastatic ferment of the intestine and the pancreatic 
juice, which transform the polysaccharide into monosaccharide. 



1 These tubes may be obtained from E. Greiner, 51 William Street, New York. 



13G NUTRITION. 

Before the starches and sugars are absorbed by the walls of the intes- 
tinal tract, they must be transformed by means of ferments found in the 
saliva, pancreatic se'cretions and intestinal juices. 

There are two classes of ferments: the "amylolytic" or "diastatic," 
which transforms starches into sugars and dextrins, and those known as 
"invertin" ferments, which, found in the mucous membranes of small intes- 
tines and in the succus entericus, give rise to glucose, by action upon the 
various saccharoses. 

The malted foods owe their nutritional value to the presence of dextrin 
and maltose. No one will question the value of the malted foods for the 
relief of atonic constipation. The carbohydrate seems to limit the irritating 
properties of an excessive fat mixture. Likewise the carbohydrate if in a 
proper amount seems to balance the improper ratios of fat and protein 
in artificial feeding mixtures. As a rule, 5 per cent, of the food mixture 
should consist of the carbohydrate element. This, however, need not be 
considered the point of tolerance of the infant, and the carbohydrate may 
be given in a gradually increased percentage. All sugars favor water re- 
tention; hence the weight of an infant will increase with an increased per- 
centage of sugar. 

Malt Sugar. — According to Finkelstein, infants will tolerate a much 
higher mixture of maltose and dextrin than either lactose or cane sugar. 
The terms "maltose" and "malt sugar," as applied to the carbohydrate used 
in infant feeding, are inaccurate and misleading. Pure maltose is a rare 
product of the laboratory and is never employed in infant feeding. What 
is really meant is maltose and dextrin. It is of great importance that this 
maltose and dextrin should be derived properly (not by the acid process, 
but in a natural way), by the action of the enzymes of sound barley malt 
upon prime, full wheat. 

In many cases of eczema all the sugars, even maltose, should be re- 
duced or perhaps eliminated until improvement is noted. Convenient prep- 
arations on the market are Mead's dextri-maltose, to be added in do°es of 
% to 1 or more teaspoonfuls to each feeding bottle, or Loefflund's malt and 
Loefflund's maltose may be given in the same dosage. 

Milk Sugar (Lactose). — Milk sugar causes abnormal acid fermentation; 
this results in symptoms of intestinal irritation due to destruction of epi- 
thelium which interferes with the proper emulsification of fats; therefore, 
the presence of fats acts as an additional irritant and provokes loose bowels. 

When intestinal irritation exists, caused by the presence of milk sugar, 
the symptoms will continue even though the milk sugar has been greatly 
reduced, because even small quantities of this milk sugar will keep up 
lactic acid fermentation and consequent destruction of the epithelium. 

A theoretical reason for the increase in bodily weight when feeding 
sugar, is that such sugar requires a certain amount of water to hold it in 



PROTEIN. 137 

suspension. Large quantities of sugar have a decided influence on the tem- 
perature of the body. A rise in temperature will follow when a large dose 
of glucose is given, and a higher fever curve will be noted when a dose 
of 15 to 30 grams of lactose has been given. For older children y> to 1 
teaspoonful of milk sugar given three times a day will relieve constipation. 

Cane Sugar (Sucrose). — Cane sugar is less irritating to the intestinal 
mucosa than milk sugar. It is easily assimilated, and for this reason has 
many advocates. For many years it has been advocated by Jacobi. I have, 
seen good results therefrom. When malt sugar cannot be procured, my 
advice is to use cane sugar. It does not possess laxative properties. When 
cane sugar is used no more than 2 to 3 per cent, of the total quantity of food 
should be ordered. 

Cane sugar is employed in commerce to preserve milk foods, which 
proves that this form of sugar possesses antibactericidal properties. 

Protein. 

Under this heading we include casein and albuminoids. Protein is 
the most important constituent of food. To sustain life, to increase growth, 
to reproduce cell waste, and to develop the organism, especially muscle, 
bone, and teeth, we need protein. In combination with a sufficient quantity 
of fat, carbohydrate, and salts, the physiological development of the body 
takes place. The nitrogenous waste of the cells of the body can be replaced 
by no other element but protein. It can readily be seen that a deficiency 
in the development, growth, and maintenance of the infant's body depends 
largely on the assimilation of protein. According to Pavy, the nitrogenous 
compounds are mainly "histogenetie" or tissue-forming material. By the 
separation of urea which occurs in this metamorphosis in the animal sys- 
tem a hydrocarbonaceous compound is left which may be appropriated to 
heat production. 

The protein element in milk is best adapted for infants. This animal 
food can be replaced only temporarily by vegetable protein. Temporary 
success may be noted in many varieties of feeding, especially when large 
quantities of carbohydrates, be they sugars or starches, are fed to the infant. 
When a large gain in weight is desired, then starches and sugars are indi- 
cated. Disaster will invariably result from the prolonged feeding of ex- 
cessive quantities of carbohydrates if the protein is deficient. Not so many 
years ago, protein was regarded as the element in food causing the greatest 
disturbance. Chees}^, curded stools thought to be casein indigestion were 
later found to be fat particles, and the curded masses were proven to be 
saponified fats. 

Further research has demonstrated that colic, eructations, and vomit- 
ing are most frequently caused by an excess of fat. What was supposed to 



138 NUTRITION. 

be the harmful element and the food element mostly feared, namely, protein, 
is now proven to be the element giving us the least concern. 

An excess of protein has decided therapeutic virtues and its indication 
in the treatment of catarrhal colitis in infancy has been established. Not 
more than a dozen years ago our literature warned against giving an excess 
of protein, and advised giving % to 1 per cent, in a feeding mixture. Ee- 
search studies, combined with careful clinical observations, have demon- 
strated the fact that double the quantity of protein can easily be 
assimilated. 

The protein molecule is peculiar when compared with the carbohydrate 
molecule. The toxicity of some varieties of the protein molecule due to the 
action of the intestinal ferments or the intestinal bacteria will be appre- 
ciated when we consider the end-results, such as fever, rash, and general 
prostration; then we have anaphylaxis. 

There is a decided difference between the protein of cows' milk and 
woman's milk. Boggs 1 states that if a solution of phosphotungstic and 
hydrochloric acid are added to milk in an Esbach tube, after twenty-four 
hours the protein will precipitate and the amount can be read off. 

When we examine the protein of woman's milk, we find the analysis 

shows: — ■ 

Woman's Milk Cotes' Milk 

Caseinogen Small Amount Large Amount 

Lactalbumin Large Amount Small Amount 

In woman's milk Konig finds the lactalbumin is about two-thirds and 
the caseinogen about one-third of the total protein. In cows' milk the 
lactalbumin is only one-sixth to five-sixths caseinogen. 

As an infant grows older, its power to digest casein becomes propor- 
tionately greater. In the latter months of infancy, the tenth, eleventh, 
and twelfth, its proteolytic function has become adapted to this change in the 
ratio of the caseinogen and lactalbumin, so that the higher total protein, 
such as 2.50, 3, 3.50, and, finally, 4 per cent., with the relatively high 
caseinogen and low lactalbumin, become the proper nutritive portion for 
the infant. 

Albuminoids in Cows' Milk. 

That there are differences in the amounts of the albuminoids occurring 
in human milk is proven by the fact that, while Professor Leeds found a 
variation of 0.85 to 4.86, Professor Meiggs asserts that there was but 1 per 
cent. 

Konig, an earlier analyst, makes the variation from 0.85 to 4.86. Some 
of these results give as high a percentage of albuminoids in woman's milk 
as we find in cows' milk, and I have no doubt in my own mind that the time 



Boggs: Johns Hopkins Bulletin No. 187, Oct., 1906. 



COWS' MILK. 139 

and habit of extracting the milk has a deal to do with the amount of occur- 
ring albuminoids. In other words, when milk is extracted every two hours 
or less, it cannot contain as much of the cell-material as milk from the same 
source extracted at intervals of twelve hours. This latter is riper, and it is 
the non-conformity of the tissue which causes all the difference in the dif- 
ferent occurring albuminoids. We know that during the incubation of eggs 
casein is developed from egg-albumin. This illustrates the ripening of albu- 
min. Furthermore, take an egg just laid by the hen, and boil it, and you 
will find immature albumin in it, that is, after boiling, instead of being 
thick and firm, like an older egg. much of it is milky. If boiled a few hours 
later, all the albumin will coagulate perfectly, because it has had time to 
ripen. There is no doubt that the albuminoids in milk from healthy animals 
are all cell-transformations, not an exudate, as are undoubtedly the fats and 
salts, because these latter we can influence by the food very plainly, but in 
health the albuminoids are constant without regard to food, while during 
menstruation, pregnancy, and other conditions, notably febrile disturbances, 
we find the fats and salts not materially affected, but the albuminoids de- 
creased, increased, or totally changed, as in the case of colostrum. The 
casein, besides being riper in cows' milk, by reason of its stronger growth, 
is intended by Nature to coagulate into a hard mass, because it is the product 
of a cud-chewer for the nourishment of a cud-chewer, and the reason why 
it does not always coagulate in the infant's stomach as it does in that of 
the calf is that the latter animal's stomach secretes a principle called chy- 
me-sin; this is the principle that curdles cows' milk, and it operates either 
in an acid or an alkaline medium. Pepsin will not coagulate milk, and 
hence the hard coagulum of cows' milk that sometimes forms in the infant's 
stomach is due to acidity of that organ, and this acidity is not always the 
fault of the stomach, but of the milk itself. The variations in the chemistry 
of the albuminoids found in cows' milk would not be surprising to anyone 
if he would examine into the condition of some of its mammary sources. 
Thus it will often be found, on dissecting a cov/s udder, that there are old 
cicatrices, t>ne or more quarters of the udder intensely inflamed, sometimes 
a mammiferous duct clogged with a calculus or a clot of fibrin. Besides 
these pathological conditions, the mammary gland is subject to benign and 
malign infiltrations, bacillary tubercular, deposits, and eruptive diseases of 
the skin involving the gland and ducts. Therefore, that fibrin, serum, and 
albumin, in various forms, are found in the cow's milk is not surprising, and 
it can safely be assumed that any variation in the albuminoids from the 
normal casein can be ascribed to sickness on the part of the animal. 

Curds in Cows' Milk. — Milk curdles under two entirely distinct 
sets of conditions: (1) it curdles on addition of an acid, and (2) it curdles 
under the influence of rennet (when the reaction of the milk is either neutral 
or slightly acid). The two varieties of curds which may be obtained under 



140 NUTRITION. 

these circumstances may be denominated "acid curds" and "rennet curds/' 
respectively. Acid curds must inevitably be formed in the stomach after 
milk has been drunk, if the gastric contents are allowed to become acid. 
Such curds (we are familiar with them in ordinary life in the form, for 
instance, of cream-cheese or sour-milk) are probably not sufficiently firm to 
set up digestive disturbances. On the other hand, rennet curds (such as we 
are familiar with in the form of renneted milk and of ordinary cheese) may 
be extremely firm. 

Casein. 

Casein can be fed to very sick infants and will be assimilated in small 
or in large doses. Casein stimulates alkaline secretion; hence, acts 
antagonistic to pathological acid fermentation. Casein is, therefore, indi- 
cated to combat diarrhoea. This teaching, based on experimental feeding, 
reverses our former theories concerning the dangers of giving large per- 
centages of protein. This form of food, recommended by Finkelstein, of 
Berlin, has gained a strong foothold in many clinics abroad. It has been 
successfully used by me in cases of intestinal disturbance, enteritis (dys- 
pepsia), atrophy (decomposition), and cholera infantum (intoxication). 
Fever, if present, does not contraindieate the use of this food. It has a 
low sugar and a low salt content. 

Casein Milk (Eiweiss Milch; Albumin Milk). — The milk is prepared 
as follows 1 : Heat 1 quart of full milk to 100° F. Add 4 teaspoonfuls of the 
essence of pepsin and stir. Let this mixture stand at 100° F. until the 
curd has formed (this usually takes about one-half hour). Filter the 
whey from the curd by means of a linen cloth, and discard the whey. 
The curd is then removed from the cloth and pressed through a rather fine 
seive two or three times by means of a wooden mallet or spoon. One pint of 
water is added to the curd during this process. The mixture should now 
look like milk, and the precipitate must be very finely divided. To this 
mixture 1 pint of buttermilk is added. 

The composition of this "casein milk" is as follows : — ■ 

Protein . 3.0 per cent. 

Fats ". 2.5 per cent. 

Sugar 1.5 per cent. 

'Salts 0.5 per cent. 

Casein milk should be given in small quantities 2 to 4 ounces in 
enteritis, and in large amounts 6 to 8 ounces in atrophy, every three or four 
hours, depending on the age of the infant. Sugar should not, be added until 
the stools are homogeneous. Until sugar is added the weight does not 
increase. Malt sugar or cane sugar should be used. This method of feeding 



Archives of Pediatrics, August, 1910. 



MINERAL SALTS. 141 

'should be continued for months, but should always be used as a corrective 
for the gastrointestinal disturbance. It should be used as a substitute feed- 
ing if artificial feeding disagrees or deranges the gastrointestinal tract. 



'a 



Mineral Salts. 1 

The growth of the body requires salts. Such salts are found in human 
milk and in cows' milk; thus, calcium, phosphorus, and magnesium neces- 
sary for bone building form a large part of the ash. Cows' milk contains 
more than twice as much potassium, five times as much sodium, phosphorus, 
and calcium, four times as much magnesium and chlorine, and six times as 
much sulphur. 

From the studies of Blauberg, Soldner, and Hoobler, we note that the 
ash intake in artificially fed infants is six to nine times greater than that of 
breast-fed infants. 

Calcium. — -Of the ash in woman's or cows' milk one-fifth consists of 
calcium. It usually enters the body in organic form. The organic com- 
bination is present in milk, yolk of egg, and vegetables. Calcium is the 
largest mineral constituent of the body. It is present as calcium phosphate, 
which makes up a large part of the bone salts. Jacques, Loeb, and Blau- 
berg have shown that infants who cannot metabolize calcium cannot survive. 

The calcium intake in cows' milk feeding is about, eight times greater 
than in woman's milk; the amount actually absorbed and retained is 
four times greater on cows' milk than on woman's milk. However, a much 
larger percentage of woman's milk calcium is retained. It is evident, there- 
fore, that the calcium of woman's milk is much better metabolized than the 
calcium of cows' milk, and, since a healthy nursing infant shows no signs of 
a deficiency of calcium, we may well consider the amount which it gets as 
being the true calcium need. The absorption of calcium depends in part 
on the presence of accompanying salts; for example, if much alkali bases 
are present in the intake the absorption is diminished, whereas NaCl assists 
in calcium absorption. Calcium is more readily absorbed on flesh than on 
a vegetable diet. 

Woman's milk and cows' milk contain very small quantities of iron. 
Were it not for the large amount stored in the liver and blood of the new- 
born there would be a deficiency in the early months of feeding. 

The organic forms occur in the nucleoalbumins, in milk, yolk of egg, 
and in many vegetables. 

Phosphorus. — Organic phosphorus occurs in milk, eggs, and legumes. 
As an organic combination it is found as nucleoalbumin, nuclein, vitellin, 
casein, and lecithin. The nucleins make up 41.5 per cent, of the total 



1 T am indebted to Raymond Hoobler for many points in the preparation of 
this article. 



142 NUTRITION. 

phosphorus of woman's milk, while in cows' milk only 6 per cent, is in that 
form. In woman's milk 35 per cent, of total phosphorus is in the form of 
lecithin, while the lecithin of cows' milk is but 5 per cent., according to 
Stocklasa. 

Sodium and Potassium. — It should be remembered that both alkaline 
and acid solutions exist within the same body; that the blood, various 
secretions, as well as each body cell, have a definite amount of alkali, and 
can vary only within very narrow limits, in order that they may perform 
their proper functions. This automatic regulation of alkalinity of the tissues 
and fluids is one of the marvels of the human mechanism, and it is remark- 
able how rarely it varies sufficiently to produce a pathogenic condition. It is 
for the maintenance of this stupendously important work that the fixed 
alkalies, sodium 'and potassium, are used. Albu and Neuberg 1 have ex- 
plained this self-regulation thus : Through the tearing down of the albumin 
of the body and the albumin taken in in the food, sulphuric and phosphoric 
acids are set free and must be neutralized by the alkalies of the blood. 
These acids would draw out the fixed alkalies were it not for the supply of 
carbonate derived from the carbonic acid and from the vegetable salts taken 
in the food. At certain times when the breaking down of albumin is ex : 
cessive, ammonia is also set free and this is used along with the carbonates 
for the fixing' of the acids. By means of this sort of neutralization, the 
acids become a constituent of the body, the fixed alkalies remain untouched, 
and the alkalinity of the tissues is unchanged. Should this reaction suffer 
the least change, either through a lessening of the bases or an increase of 
the autogenous acids, the organism becomes at once in danger. 

Sodium Chloride. — Of all mineral constituents, sodium chloride has the 
most important function to perform. Not only does it retain but it ex- 
cretes water. Because of the well-known fact that salt requires water for its 
retention, the salt-free diet was suggested to relieve oedema and thereby 
favor excretion of water. Sulphur is found in woman's as well as cows' 
milk, but its importance has not yet been fully determined. 

Hoobler concludes as follows : Salts are necessary to maintain life. 
They are best absorbed and utilized when in organic combination with food- 
stuffs. There are marked differences in the salt content of woman's and 
cows' milk which should be considered in artificial feeding. Certain 
pathological conditions arise in which certain of the salts are not absorbed, 
even though in abundance in the food. In certain other pathogenic condi- 
tions salts are actually withdrawn from the body to such an extent as to im- 
poverish the organism and produce grave disturbances of nutrition. The 
various salts, with the exception of iron, are present in sufficient quantities 
and proper proportions in woman's milk. In most of the dilutions of cows' 



1 Mineralstoffwechsel, Berlin, 1900, p. 70. 



MINERAL SALTS. 143 

milk there is an excess of salts, which may be neglected in feeding normal 
infants, but which plays an important role in the feeding of children already 
suffering from nutritional disturbances. The conditions under which the 
salt content of feedings should be altered, and in just what degree each or 
all should be varied, are still unsolved problems. 

The Addition of Lime-water, Bicarbonate of Sodium, or 
Other Alkalies to Cows' Milk. 

Lime-water is the alkali usually selected for neutralizing the acidity 
in cows' milk. It acts by partly neutralizing the acid of the gastric juice, 
so that the casein is coagulated gradually and passes, in great .part, un- 
changed into the intestine, to be there digested by the alkaline secretions. 
As it contains only y 2 grain of lime to the fluidounce, the desired result 
cannot be attained unless at least a third part of the milk-mixture be lime- 
water. Instead of lime-water, 2 to 4 grains of bicarbonate of sodium may 
be added to each bottle, or, better still, from 5 to 15 drops of the saccharated 
solution of lime. 

This solution is made in the following way: — 

Ifc Slaked lime 1 ounce 

Refined sugar, in powder 2 ounces 

Distilled water 1 pint 

Mix the lime and sugar by trituration in a mortar. Transfer the 
mixture to a bottle containing the water, and, having closed this with a cork, 
shake it occasionally for a few hours. Finally, separate the clear solution 
with a siphon and keep it in a stoppered bottle. 

Bicarbonate of Soda Solution {Baking Soda). — Take 1 grain of soda 
bicarbonate to % ounce of water. Or 1 drachm of soda bicarbonate to 1 
quart of water. This is the proper strength used for diluting milk. 

Quantity to be Used. — One tablespoonful of the last-named solution 
equals in strength 1 tablespoonful of ordinary lime-water. 

Both lime-water and soda-bicarbonate solution should be kept in very 
clean, well-stoppered bottles and in a cool place. 

The teaching that lime-water should be added to render cows' milk 
alkaline, and thereby resemble human milk, has been studied by Kerley, 
Gieschen, and Meyers, whose conclusions are very interesting. They say 
that :— 

1. Breast-milk and cows' milk are both acid. 

2.' The litmus-paper test for milk is unreliable because of the varia- 
tion in the quality of litmus paper, and the litmus taking part in the 
reaction and not acting as an indicator. 

3. The effect of adding lime-water or bicarbonate of sodium to feeding 
is to retard or inhibit the formation of curds by rennet. 



144 NUTRITION. 

4. The teaching that lime-water, bicarbonate of sodium, or carbonate 
of potassium should be added to fresh milk or feedings simply because they 
are antacids is erroneous. 

5. The addition to milk or feedings of alkalies or salts that become 
alkaline in solution is an empirical method of aiding digestion by prevent- 
ing the formation of dense curds that would slowly leave the stomach and 
be difficult of digestion in the intestine. 

In one respect I do notf agree with them, and that is in regard to the 
addition of bicarbonate of potassium. In weak infants, especially in maras- 
mic cases and in those infants in which "milk colic" appears one or two 
hours after being fed with cows' milk, P have found that by the addition 
of 10 to 15 grains of bicarbonate of potassium to each feeding improve- 
ment was invariably noted. I have not found this improvement when 
bicarbonate of soda or lime-water was added. 

VlTAMINES. 1 

Vitamines are found in the external shell or kernel of the cereals. 
They can be extracted in the form of colorless, needle-shaped crystals. They 
are necessary as'a live factor in nutrition. If we give a cereal minus the 
hull or shell we deprive the child of one of the most important elements of 
its nutrition — namely, its vitamine. 

It has been experimentally proven that scurvy, rickets, and beriberi 
can be developed by giving food lacking in vitamine. ' On the other hand, 
the disease can be arrested and cured by adding the vitamines to the food. 

The absence of vitamines in the food is responsible for the development 
of specific diseases, which have been called deficiency diseases or avitaminosis. 
Rickets, scurvy, or Barlow's disease, pellagra, and beriberi are some of the 
diseases belonging to this group. 

When pigeons are fed on rice from which the vitamines have been 
removed they linger and die. It has been found that by feeding adults or 
children rice from which this substance has been removed beriberi will result. 
Funk found that when this specific vitamine was given to such patients, 
although fed on polished rice,, they recovered. 

Rickets was formerly believed due to a lack of sufficient protein and 
fat in the diet. It is now recognized that rickets is most likely due to the 
absence of vitamines, which are necessary for the proper metabolism of fat 
and protein. That the vitamines stimulate the thymus and the parathyroids 
seems plausible, and when they are absent from the food there results either 
rickets or tetany. 

Vitamines are found in the brain of the ox, also in lecithin and in 
testiculin as sold in commerce. Cereals such as oats, wheat, barley, and 
various kinds of beans contain vitamine, so also fresh vegetables. 



'Die Vitamine, by Casimir Funk, Wiesbaden, 1914. 



PLATE V 




Microscopic Appearance of Raw Starch-granules. 



PLATE VI 




Microscopic Appearance of Starch granules, showing the effect of Heat. 



STARCH. 145 

Vitamines are best administered in the form of yeast with yolk of egg. 
Funk has found that beriberi is not due to an infection or intoxication, but 
is caused by a deficiency of this vitamine. 

The absence of vitamine is noticeable in polished rice, white bread and 
starch. If to this food we add yeast or beans, then we add vitamines which 
are required for the development of the organism. 

Vitamines in milk are sometimes dependent on the nutrition of the 
cows ; thus we find that milk of cows lacking fresh fodder, as for example in 
winter, will produce less vitamines. It is, therefore, quite plausible that the 
use of such milk may be a factor in the causation of rickets. Funk states 
that the vitamines are practically destroyed by moderate heating of milk, and 
are completely destroyed by the sterilization of milk. We can, however, add 
vitamines to sterilized milk and thus render it nutritious and also anti- 
scorbutic. 

Antiscorbutic Diet. — Fresh green vegetables like lettuce, cauliflower, 
onions, potatoes, apples, oranges, lemons, raw milk, yolk of egg, meat, 
wheat, oats, and barley. 

Juicy fruits and vegetables lose their vitamines (scurvy vitamine) en- 
tirely on drying or heating to 212° F. for one hour. The action of the 
vitamines resembles that of hormones and the secretions of the ductless 
glands. Albuminous substances vary in their nutritive value depending on 
the presence or absence of amino-acids. In like manner there are certain 
foods the value of which is dependent on their vitamine content. Chemical 
examination shows that vitamines occur in maize in very similar fashion to 
rice in the peripheral layers. 

Enzymes (Effront and Prescott). 

The enzymes, soluble ferments, zymases, or diastases, are active organic 
substances- secreted by cells, and have the property, under certain conditions, 
of facilitating chemical reactions between certain bodies, without entering 
into the composition of the definite products which result. These substances 
play a very important part in the phenomena of assimilation and of dissimi- 
lation of foods. In fact, most of the foods which occur in Nature at the 
disposition of men, lower animals, or plants are not directly assimilable; 
they require the intervention of a diastase in order to be transformed into 
substances assimilable and suitable for the formation of new tissues. 

Starch. 

Amylaceous dilutions of milk have been in use very many years. They 
increase the carbohydrate ; besides aid mechanically in breaking up the curd 
into fine particles, thus rendering it more digestible. The saliva of the 
newly born infant can dextrinize starch. Starch is not assimilated as such, 

10 



146 NUTRITION. 

but is transformed into maltose and glucose. These latter are suitable for 
the construction of tissues. 

Cereals. — In the feeding of infants we should give sugar to supply the 
carbohydrate element in preference to starchy foods. Cereals should not be 
ordered until the infant is six months old or until the teeth begin to appear. 
Experience has shown fair quantities of starch can be digested as early as the 
third month. My method has been to use cereal dilutions such as barley 
water or rice water to dilute cows' milk after the third month. When the 
infant is 6 months old it is safe to feed a small saucer of well-steamed 
cereal, but care must be used to avoid starch indigestion, which condition is 
brought about by improper cooking of cereals and by overfeeding -or feeding 
excessive quantities of carbohydrates. 

Cream. 

When food contains too little fat, or its equivalent (cream), we have 
fat-starvation, which is soon manifested by symptoms of rickets. One of 
the earliest symptoms of rickets is constipation, showing deficient muscular 
tone : a distinct atony of the bowel. 

This can be remedied by the addition of fat or cream to the food. 
Some children are benefited by giving them codliver-oil, butter, or olive-oil; 
thus, it is plain that each one desires to remedy the deficiency of fat in his 
own manner. 

In buying cream from small milk-stores one can make a rough .guess 
at the proportion of fat in cream by its thickness. A 50-per-cent. cream at 
the ordinary temperature of the room runs from a jug slowly and in a 
thick stream, almost like thick mucilage, whereas a 16 per cent, cream 
runs almost as freely as milk. This is, however, a crude way of estimating 
the difference between poor and rich cream. It is a very important point 
to know exactly what percentage of cream we are using, for such mixtures 
like Biedert's, in which 1 ounce of cream is mixed with 3 ounces of water, 
may agree very well when we use a 16 or 20 per cent, cream, but might be 
disastrous if we use a cream containing 40 per cent, of fat. Such infants 
would not tolerate this rich cream, and might have troublesome vomiting. 

Cream for Home Modification. — Ordinary Cream: This is made by 
setting milk at night and skimming it in the morning; it is called gravity, 
or skimmed, cream, and contains 16 per cent, of fat. 

Twelve Per Cent. Cream. — Obtained in the city by using equal parts 
of ordinary (20 per cent.) centrifugal cream and plain milk. In the 
country we must use 2 parts of ordinary skimmed, or gravity, cream (16 
per cent.) with 1 part of plain milk, or by taking the top layer of milk, 
after it has stood five or six hours, by means of siphoning. 

Eight per cent, cream is obtained in the city by diluting 1 part of cen- 
trifugal (20 per cent.) cream with 3 parts of plain milk; in the country, 



CREAM. 



147 



by using 1 part of gravity cream and 2 parts of plain milk, or by using the 
top layer of milk that has been standing five or six hours, siphoning it off. 

How to Procure Cream. — Set aside the ordinary quart bottle of milk 
on the ice for several hours (from six to eight hours) to allow the cream to 
rise. After the cream has risen draw the milk from the bottom of the 
bottle ; this can be accomplished by means of a siphon. 

To make the siphon, get a piece of glass tubing 21 inches in length and 
a quarter of an inch in caliber. This can be procured in any drug store. 
German glass is less liable to crack than American glass. If the glass tubing 
is longer than 21 inches make a small scratch in it, after measuring off 21 
inches, with a three-cornered file, then grasp the glass tubing between the 
fingers and opposing thumbs of both hands, having the thumb-nails touch- 





*^ 




Fig. 48. — Chapin Cream Dippei 



ing each other on the side of the glass just opposite to the scratch. On 
attempting to bend the glass tube it will break smoothly across, and if 
there are any sharp edges they can be smoothed by rubbing down with the 
file. 

To bend the glass tube to the V shape, hold it in the flame of an ordi- 
nary gas jet or alcohol lamp for a few moments, twirling the glass rod until 
it softens sufficiently to allow it to be bent to the required angle. The tube 
should be warmed gradually at first, and then put right into the flame. It 
is better in bending the glass to make one arm of the siphon a few inches 
longer than the other. 

In using the siphon hold it with the angle down, fill it with water, 
and close the long arm with the tip of the finger; then, keeping the finger 
applied to the long end, turn the siphon with the angle up, and introduce 
the short arm into the bottle of milk, letting it rest upon the bottom. On 
removing the finger, the milk will flow through the tube, and continue to 



148 NUTRITION. 

do so until the bottle is empty. It is, therefore, necessary to watch the 
layer of cream, so that the siphon can be lifted out of the bottle just before 
the cream reaches it. There will thus remain in the milk-bottle all of the 
cream and a small portion of the milk, the latter depending upon the ex- 
pertness of the person using the siphon. 

A simpler method of obtaining the cream is by the use of a cream 
dipper (see Fig. 48). This can be purchased at any large drug-store. The 
illustration explains itself. 

To Pasteurize the Cream. — Take a clear glass bottle having a neck not 
very wide; fit into the same a perforated cork with a chemical thermom- 
eter registering up to 212° F. The bulb of the thermometer should come 
within half an inch of the bottom of the bottle. The cream is put into the 
bottle, and the cork carrying the thermometer is inserted; the bottle is 
then placed in a pot containing a couple of inches of warm water and 
allowed to heat on the stove. The thermometer should be watched until 
it reaches 140°, taking care that it does not go above 140°. When the ther- 
mometer has reached this point, set the pot back on the stove, where it will 
cool off, and allow it to remain there for twenty minutes. At the end of 
this time substitute a plug of absorbent cotton for the cork containing the 
thermometer. Great care must be taken to keep the absorbent cotton dry. 
Cream thus prepared is pasteurized, and will keep sweet and fresh for 
twenty-four hours without being kept on ice, and all that is necessary in 
removing a portion from the bottle is to be sure that the cotton plug does 
not become moist, or, if it should, to replace it with a dry piece at once. 

To Clean the Glass Siphon. — It is advised to fill it with water imme- 
diately after using it, and the ordinary tube-brush having eighteen 
inches of wire added to it will permit thorough cleansing. Nothing, how- 
ever, will be found as good as thorough boiling in plain water to which a 
pinch of soda has been added. 

Modification of Milk. — It has been shown previously that the percent- 
ages of fat in woman's and in cows' milk are about the same, that the 
quantity of sugar is rather lower in cows' milk, and that the quantity of 
casein and albumin is greater in cows' milk, as is also the ash. Experience 
has shown that cows' milk must be diluted before it can safely be fed to 
infants. Simply diluting the milk reduces the percentages of fat and sugar 
too much; so that the practice of adding cream and sugar has arisen, but the 
processes that have been advocated for obtaining the desired additional 
quantities of fat and sugar have been too complicated for general use. 

The top 9 ounces of a quart of milk on which the cream has risen will 
be about three times as rich in fat as the whole milk, the top 15 or 16 
ounces will be about twice as rich as the whole milk, while the other 
ingredients remain about the same as in whole milk. 

For babies under three months of age the top 9 ounces of a quart of 



CREAM. 149 

milk on which the cream has risen should be diluted from three to ten 
times and 1 part of sugar added to 25 parts of food. 

For babies under three months of age the top 9 ounces of a quart of 
milk on which the cream has risen should be diluted two or three times 
and 1 part of sugar added to 25 or 30 parts of food. 

For babies six to nine months old the top 20 ounces of a quart of 
milk on which the cream has risen should be diluted one-half to one time 
and 1 part of sugar added to 50 parts of food. An even tablespoonful of 
granulated sugar equals half an ounce. 

By following this method the infant commences on weak mixtures 
that show about the same composition and variations as woman's milk 
and gradually takes food richer in casein until plain milk is reached. 

The diluents used are water, gruels, or dextrinized gruels, which are 
simply ordinary gruels the starch of which has been converted into soluble 
forms, leaving the cellulose and proteins of the cereal in a finely divided 
state. The effect of the different diluents will be mentioned farther on. 

The indiscriminate feeding of cream, to strengthen the bab} r , cannot 
be too strongly condemned. Many a dyspeptic owes his trouble to over- 
feeding by a too good mother or nurse. When cream is added, and the pro- 
portion of fat or protein is too large, vomiting will result. Stuffing delicate 
children with cream, regardless of their digestive power, cannot be too 
strongly condemned. When improper food is given, and the infant's stom- 
ach is overtaxed, the excess of food irritates and may cause vomiting. If, 
however, the food remains, then the gastric mucosa is inflamed by bacterial 
fermentation of stagnant food. This may result in diarrhoea or in fermen- 
tative gastritis, and cause chronic enlargement of the stomach. 



CHAPTER III. 

HOME MODIFICATION OF MILK. 

Bottle-feeding or Hjnd-eeeding. 

The following utensils are required for the 'home modification of 
milk : — 

Two-quart pitcher, "j 

Funnel, V glass or porcelain. 

One large spoon, J 

One dozen 4-ounce bottles (later substitute 8-ounce bottles). 

One dozen anticolic nipples. 

One box non-absorbent cotton. 

One saucepan (for heating milk). 

One high saucepan (for warming bottle before feeding). 

Feeding-bottles. 

A proper feeding-bottle is one that has no corners or angles on the 
inner surface. The bottom should be rounded, so that every part of the 
same can be properly cleaned. Bottles that have corners and grooves will 
harbor bacteria. 

My preference has always been for two kinds of bottles: 1. Those 
holding 4 ounces and graduated on one side in both ounces and tablespoons ; 
this saves much time and trouble. 2. Bottles holding 8 ounces and divided 
off into 16 tablespoonfuls or 8 equal ounces. 

Exactness of Ounces. — It may not be out of place to ask each physician 
to insist on having the graduated ounces on an infant's feeding-bottle meas- 
ured with an accurate graduate, obtainable at every drug store. In many 
instances the author noted feeding-bottles wherein the ounces indicated 
were very unequal, and one particular bottle, graduated to 8 ounces, held 
12 ounces. 

Long Rubber Tubes. — Most prominent pediatrists agree that the long 
rubber tubes are a convenient place for harboring micro-organisms, and they 
have been universally condemned. 

Care of the Bottle. — Every bottle should be thoroughly cleaned with 
a brush and a solution of baking soda and water, a teaspoon of soda to a 
pint of water. The bottles must then be thoroughly rinsed with clear water. 
If milk has fermented or if some residue adheres to the bottle and the same 
cannot be properly cleaned, then boiling the bottles will be necessary. In 
general and for daily use the bottle need not be boiled every day. 
(150) 



FEEDING-BOTTLES. 



151 



Proper Time for Cleaning Bottles. — The best time to clean a bottle is 
immediately after the baby has been fed ; this prevents the food souring 
in the bottle, and it is very easily cleaned. 

The bottle brush has a long handle and bristles for cleansing the bottles. 
This brush' should be used before the bottles are put into the soda solution. 
It is understood that the brush can itself harbor bacteria and particles of 
milk removed while cleansing. It is therefore understood that the brush 
must be thoroughly boiled in a soda solution after each use. 

Choice of a nipple is another important matter. My preference has 
always been for a black-rubber nipple, and it is a very wise point to use a 
nipple no longer than one week; in other words, old, worn nipples are useless 
for the proper management of infant-feeding. Black rubber is softer than 





Fig. 49 Fig. 50 

Fig. 49. — Author's Choice of Feeding-bottle. 

Fig. 50. — Bottle Warmer. A convenient bottle warmer, adapted for 
keeping the night feeding warm, is here illustrated. It is made by the 
Arnold Sterilizer Co. It is also useful when traveling. 

white rubber; most white rubber is supposed to contain lead; hence a 
decided reason for not using it. 

Nipples Recommended. — One of the best nipples made is the so-called 
anticolic nipple. This nipple has a ball-shaped top, which enables a baby 
to take a firm hold; it has three small holes, which give an easy flow of 
milk, and regulate a slow meal. Nipples having very large openings, which 
will permit a baby to finish a 6- or 8- ounce bottle of food in five or six min- 
utes, are useless, and this gulping of food is really the cause, or one of the 
causes, of infantile colic. 

I have used another nipple, but it is much harder to clean, and unless 
all precautions for sterilization are carefully noted it should not be used; 
yet, in the hands of the intelligent or where we have a trained nurse, it can 



152 



NUTRITION. 



be safely recommended. It is called the "Mizpah." This nipple has also 
a very small puncture, so that the baby gets the food slowly. 

The "swan-bill" nipple and the long French nipple I also like. I have 
noted just as good results as with the above-mentioned kinds. 

Ventilated Nipple. — A nipple very highly spoken of is the ventilated 
nipple made by Ware, of Philadelphia, which has a small opening or valve 
on the side, and, as the milk is drawn in from the bottle, it permits air to 




Fig. 51.— Bottle-brush. 

enter, thus preventing a vacuum from being formed. It is also supposed to 
be non-collapsible, and is highly recommended by those who have used it. 
The only objection — already offered — is that all nipples must not only be 
practical for use, but must be capable of thorough sterilization. 

Cleaning the Nipples. — The prevention of stomatitis and mouth affec- 
tions depends upon proper hygiene of the nipple. It does not require much 
time or trouble to remove the nipple from a bottle and throw it into boiling 
water immediately after using, wrap in sterile cheesecloth, and keep in a 
covered jar. A nipple thus treated is properly sterile. 




Fig. 52. — Anticolic Nipple. 

The nipple sterilizer (see Fig. 53) is a very convenient little arrange- 
ment made by Ware, of Philadelphia. It serves the purpose admirably for 
the sterilization of nipples. 



Sterilization of Milk. 

When Soxhlet first announced the method of sterilization, he awoke the 
profession to the realization of the dangers lurking in crude cows' milk 



STERILIZATION OF MILK. 153 

His aim was to destroy pathogenic bacteria, and give the infant a milk 
which did not contain living bacteria. 

In order to sterilize milk, according to Soxhlet, we must heat milk 
to a temperature of 212° F. and continue this steaming for thirty minutes. 
We know that heating milk produces many changes, some of which are 
not thoroughly understood. Other changes have been positively proven. 

Changes in Milk Caused by Sterilization. — In some experiments made 
by Dr. E. M. Hiesland and published by Dr. B. C. Hirst, 1 it was found that 
by sterilization : — 

1. The albumin is coagulated. 

2. Casein is less readily precipitated by rennet than in normal milk. 

3. Fat is freed to a slight extent; fat not freed has a lessened tend- 
ency to coalesce. 




Fig. 53. — Nipple Sterilizer 



4. Sugar undergoes some change, as shown by its lessened dextrorota- 
tory power. 

The considerations suggested by the foregoing facts are : — 

1. The coagulation of milk-albumin by sterilization may render the 
milk more difficult of digestion. 

2. Sterilization interferes with the coagulability of milk by rennet, 
and presumably, therefore, with its digestibility by the gastric juice. 

3. Free fat, as found in sterilized milk, is probably not readily assimi- 
lated in infant food. The fat not free, being inclosed in a less easily 
destructible envelope, is probably slow of digestion. 2 

On the question of sterilized milk the weight of evidence seems to show 
that the process, while preventing undue fermentation, so changes certain of 
the natural ferments and some of the fats that the milk is less easily 
digested and less nutritious. 3 

The sterilization of milk is advocated chiefly to destroy pathogenic 
bacteria. The profession has been educated to the belief that we must kill 
all living micro-organisms in food. 



1 Medical News, January 31, 1891. 
'Medical Record, February 28, 1891. 

'North American Practitioner, June, 1892, from the "Year-book of Treatment" 
(Lea Brothers & Co.). 



154 NUTRITION. 

When the method was first advocated, the profession adopted it in all 
parts of the world ; so that thousands of babies have been brought np on 
sterilized milk. Within the last few years sentiment has changed. Sterili- 
zation accomplishes the destruction of pathogenic bacteria, but it also pos- 
sesses certain disadvantages. 

The spores of pathogenic bacteria cannot be destroyed by the ordinary 
process of sterilization. 

To properly sterilize milk it is necessary to subject it to the process of 
iyndallization. This will render milk germ-free. This latter process con- 
sists of subjecting the milk to the process of sterilization for at least twenty 
to thirty minutes on three successive days. For practical purposes it is 
useless. 

The chemical changes produced in milk by the process of sterilization 
are as follows: The lactalbumin coagulates at a temperature of 160° F. 
(70° C). Thus the temperature being 212° F. renders this ingredient 
decidedly different from what it appears in its raw state; the casein is 
rendered less coagulable by rennet and appears to be acted upon more slowly 
both by pepsin and trypsin; the organic phosphorus is changed into an 
organic phosphate; citric acid is partially precipitated as calcium citrate, 
and some lime salts, which are usually soluble, are converted into insoluble 
compounds. 

Certain changes also occur in the fat. Moreover, certain natural fer- 
ments in fresh milk, believed to be of value in digestion, are destroyed by 
heat. 

Many of these changes are but imperfectly understood, and some of 
them are doubtless without any injurious effect upon nutrition. There is, 
however, one important clinical reason for believing that the nutritive 
properties of milk are impaired by heating to 212° F., viz., the occurrence 
of scurvy in infants who are fed upon such milk for a long time (Holt). 

We know that a great many children fed on sterilized milk develop 
scurvy. The same is true of children fed on boiled milk. The reason is, 
Eundlett so ably says: "Changes take place not in the albumin, fat, nor 
sugar, but in the albuminate of iron, phosphorus, and possibly in the fluorine 
vital changes take place. These albuminoids are certainly in the milk, de- 
rived as it is from tissues that contain them, and are present in a vitalized 
form as proteins." On boiling, the change taking place is simply due to 
the coagulation of the globulin, or protein molecule, which splits away from 
the inorganic molecule, and thus renders it, as to the iron and fluorine, 
unabsorbable and, as to the phosphatic molecule, unassimilable. This is 
the change that is so vital, and this only takes place when milk is boiled. 

It is evident that children require phosphatic and ferric proteins in 
a living form, which are only contained in raw milk. 

Cheadle says that phosphate of lime is necessary to every tissue; no 



STERILIZED MILK. 155 

cell growth can go on without earthy phosphates; even the lowest form of 
life — such as fungi and bacteria — cannot grow if deprived of them. These 
salts of lime and magnesia are especially called for in the development of 
the bony structures. 

Avoidance of Scurvy. — Since clinical experience has demonstrated that 
the prolonged use of sterilized milk and boiled milk will produce scurvy, 
and that improvement is immediately noted when raw milk is given, or 
raw muscle juice (beef-juice) or raw white of egg, added to fresh fruit 
juices, does it not seem more plausible to commence feeding at once with 
raw milk rather than after scurvy or rickets is developed? 

There is a certain cleadness, or, to put it differently, absence of fresh- 
ness, that is lacking in milk that has been boiled or sterilized, just as it is 
the absenee of fresh meats and green vegetables which is known to cause 
scurvy in the adult. 

In my own practice I have so frequently been disappointed in the use 
of sterilized milk that within the last few years I have entirely discarded 
its use. 

The Disadvantages of Sterilized Milk From a Clinical Standpoint. — 
The first effect of using sterilized milk is that the child will be con- 
stipated. It is for this reason decidedly objectionable. It is wise to re- 
member that one of the earliest symptoms of rickets is constipation. We 
have known that the prolonged use of sterilized milk results in rickets. 
The symptom of constipation should therefore be looked upon not as a 
temporary, but as a permanent, damage to the body. Therefore, it should 
not be neglected. Appropriate dietetic treatment can easily modify con- 
stipation. Clinicians all agree that the prolonged use of sterilized milk 
cannot be advocated. There may be individual children who thrive on 
prolonged use of sterilized milk, and I dare say on any form of feeding. 
We are dealing, however, with average children, and these all show a cer- 
tain train of symptoms. 

Constipation of the most stubborn kind will be encountered in all 
children fed on sterilized milk. This condition exists regardless of the 
season of the year. Children do not thrive as well on sterilized milk as they 
do on milk subjected to a much lower degree of temperature. Sterilized 
miHv is rendered less digestible than it is in its raw state. 

Freeman 1 says that the modifications produced in milk heated to 212 °- 
F. consist in the starch-liquefying ferment being destroyed, the casein 
being rendered less coagulable and therefore being acted upon slowly and 
imperfectly by pepsin and pancreatine, and the milk-sugar being destroyed. 

Fay el, 2 discussing boiled milk, says that it is more indigestible and 
in no respect safer than unboiled milk. The temperature at which it boils 



1 Paper read at Academy of Medicine, New York, May 11, 1893. 

2 Medical Age, September 25, 1893. 



156 NUTRITION. 

is insufficient to destroy microbes, and the milk is therefore not ster- 
ilized. Its density is increased by the boiling, above that suitable for infant 
digestion. 

Milk consists of a multitude of cells suspended in serum. The cells 
are fat cells, which form the cream. The remaining cells are nucleated and 
of the nature of white corpuscles. The serum consists of water in which 
is dissolved milk-sugar and serum albumin, with various salts and, chief 
of all, casein. The cells, with the exception of fat corpuscles, are all living 
cells , and they retain their vitality for a considerable time after the milk 
is drawn from the mammary glands. 1 

There is reason for supposing that when fresh milk is ingested the 
living cells are at once absorbed without any process of digestion, and enter 
the blood-stream and are utilized in building up the tissues. The casein 
of the milk is digested in the usual way as other albuminoids by the gastric 
juice, and absorbed as peptone. There is also absorption of serum albumin 
by osmosis. The chemical result of boiling milk is to hill all the living cells 
and to coagulate all the albuminoid constituents. Milk after boiling is 
thicker than it was before. 

The physiological results are that all the constituents of the milk must 
be digested before it can be absorbed into the system; therefore, there is 
distinct loss of utility in the milk, because the living cells of fresh milk 
do not enter into the circulation direct as living protoplasm and build up 
the tissues direct, as they would do in fresh, unboiled milk. In practice *it 
will have been noticed by most medical practitioners that there is a very 
distinctly appreciable lowered vitality in infants which are fed on boiled 
milk. The process of absorption is more delayed and the quantity of milk 
required is distinctly larger for the same amount of growth and nourish- 
ment of the child than is the case when fresh milk is used. 

Vaughan does not believe that milk is benefited by either sterilization 
or pasteurization, but such procedure is necessary when market milk is used, 
because the latter is seldom or never obtained under aseptic precautions. 

Some people have an idea that it matters not how filthy a cow's milk 
is, or how many germs it may contain, if it be pasteurized or sterilized it 
then becomes a fit food for children. This is not true, because, in the first 
place, even prolonged boiling does not kill the spores of all bacteria, and, 
in the second place, the chemical poisons produced by certain germs are not 
altered by the temperature of boiling milk. 

After milk has been either sterilized or pasteurized it should be kept 
at a low temperature before being fed to the child. This should be regarded 
as a necessary procedure in the preparation of infant food. The fact that 
milk in which the colon germ has already grown abundantly cannot, by 
any process of sterilization or pasteurization, be rendered fit food for chil- 



J. L. Kerr, British Medical Journal, December, 1895. 



PASTEURIZED MILK. 



157 



dren should be emphasized. The toxin of the colon bacillus may be heated 
to 180° C. (356° F.) for half an hour without having its poisonous prop- 
erties diminished. If clean milk be obtained and heated at !JfO° F. to 150° 
F. for ten to fifteen minutes and then kept at a low temperature until fed 
to the child, it furnishes the best food which it is possible for us to obtain 
under ordinary circumstances. 

Pasteurization". 

Heating milk to 75° C, as is done by many of the methods, does not 
sterilize, for the spores of the bacillus subtil is can withstand this temperature 
for several days. The spores will resist the temperature of 100° C. (212° 
F.) for six hours. Upon heating to 110° to 120° C. (230° to 248° F.) 
the milk will be thoroughly sterilized, but such heating causes a browning 
of the milk, and the cream-cells are apt to be broken and the fat or butter 
will rise to the surface. 

Pasteurization with a temperature between 60° and 80° C. (140° to 
176° F.) destroys tubercle bacilli and, according to Van Geuns, destroys 
also the typhoid bacillus, the cholera bacillus, and the pneumococcus of 
Friedlander, and also most of the ordinary milk germs, and does not injure 
the milk. 

C. H. Stewart gives the following interesting result of the heating of 
milk at various temperatures, and its result on the albumin : — 



Table No. 21. 



Time of Heating. 


Soluble Albumin 
in Fresh Milk. 


Soluble Albumin 
in Heated Milk. 


10 minutes at G0° C. (140° F.) 

30 minutes at 00° C. (140° F.) 

10 minutes at 05° C. (149° F.) 

30 minutes at 05° C. (149° F.) 

10 minutes at 70° C. (158° F.) 

30 minutes at 70° C. (158° F.) 

10 minutes at 75° C. (107° F.) 

30 minutes at 75° C. (107° F.) 

10 minutes at 80° C. (170° F. ) 

30 minutes at 80° C. (170° F.) 


Per Cent. 
0.423 
0.435 
0.395 
0.395 
0.422 
0.421 
0.380 
0.380 
0.375 
0.375 


Per Cent. 
0.418 
0.427 
0.302 
0.333 
0.209 
0.253 
0.070 
0.050 
none 
none 



We can see that heating milk at 140° F. for ten minutes or for thirty 
minutes still leaves about the same proportion of soluble albumin as we 
find in fresh milk. When milk is heated only ten minutes at 176° F. 
no soluble albumin remains, while in fresh milk about 0.375 is found. 

There is a slight taste or flavor which is noticeable when milk is 
heated to 158° F. for fifteen minutes. For practical purposes, however, 
milk heated to lJf0° F. serves very well and has no taste at all. Pasteuriza- 



158 NUTRITION. 

tion of milk has been received by the profession with the same enthusiasm 
as was sterilized milk when it was first announced. The mistakes that have 
been made by forcing infants to swallow milk sterilized at a temperature 
of 212° F. for thirty minutes are evident in so far as such children can 
show a devitalized condition into womanhood and manhood. Constipation 
and rickets are recognized as associate factors during sterilized milk feed- 
ing. The profession at large is rapidly departing from this improper and 
dangerous method of treating raw milk. 

What has been said of sterilized milk applies in a lesser degree to 
pasteurized milk. I have frequently found cases of infants fed on 
pasteurized milk that showed the same symptoms, though in a milder 
degree, than what we know to be true of sterilized milk feeding. 

When my advice is sought regarding the utility of pasteurizing milk, 
I always say: You should pasteurize your milk at a temperature of 140° to 
150° F., for ten minutes, if you do not know the source of your milk supply. 
In New York certified milk or guaranteed milk is procured, and it is un- 
necessary to change the chemical character of the milk by prolonged heating. 
With certified milk it is simply necessary to use sterile utensils and warm 
the food to a little higher than feeding temperature. 

General Eules of Bottle-feeding for Normal Infants. 

No set rule can be given for all infants. Each infant's desires must 
be studied. The stomach capacity of one infant may be 6 ounces at the 
age of two months, while another equally healthy infant will be satisfied 
with 4 ounces at one feeding. 

In the home modification of milk our aim should be to give a simple 
formula, and one that can be easily understood by the mother or nurse. 
These formulae, with specific directions added, should be written out by 
the physician, and the following conditions noted : The weight of an 
infant to be taken when a new formula is given; the character, color, and 
frequency ..of the stool to be noted; constipation or diarrhoea supervised; 
sleep and general comfort inquired into. Does the infant appear satisfied 
after its feeding, or does it put its fingers into its mouth and whine after 
each feeding ; does it draw up its legs, is it flatulent ; is there vomiting after 
each feeding, and is there frequent eructation ? 

Summary. — If the food agrees the infant should be comfortable, have 
one or more natural stools in twenty-four hours, sleep at least four hours at 
one time, and gain in weight from 4 to 8 ounces during the week. 

Caloric Method of Feeding. 

A calorie is the amount of heat necessary to raise the temperature of 1 
kilo. 1° C. The determination of the heat energy expressed by a given 



CALORIC FEEDING. 159 

number of calories can be applied in estimating the food requirement of 

infants : — 

1 gram or c.c. of fat equals 9 calories 

1 gram or c.c. of sugar equals ... .4 calories 

1 gram or c.c. of protein equals 4 calories 

The most prominent pediatrists in Europe calculate their food values 
in calories. My experience with this method of feeding has been very 
satisfactory. When the metric system of grams and kilograms is used the 
method is extremely simple. The requirement for the first three months is 
100 calories for each kilo, of weight, for the second quarter year about 90 
calories; therefore, an infant weighing 5 kilos, requires 500 calories in 
twenty-four hours. Later on, the requirement is 80 calories, and some 
infants at the end of six months do not require more than 70 calories per 
kilo. Emaciated and premature infants require 120 or more calories for 
each kilo. 

The simplest method of calculating the given number of calories in a 
pint or quart of food is as follows : — 

The caloric value of 1 ounce of 4 per cent, milk is 20; 16 times 20 
calories equals 320 calories to 1 pint, or 32 times 20 calories equals G40 
calories to 1 quart. 

20 ounces of 4 per cent, milk 20 x 20 400 calories 

12 ounces barley water 12 x 12 24 calories 

1 ounce malt-soup extract 80 calories 

504 calories 
Table No. 22. — Foods and Caloric Value of Each. 



Food, 1 Ounce. 



Cream ( 16 per cent.) 

Milk (4 per cent, cream) 

Milk (2 per cent, cream) 

Milk ( 1 per cent, cream ) 

Milk, fat-free 

Whey 

Condensed milk .' 

Buttermilk 

Albumin milk 

Malt-soup extract 

Malt-soup (formula as given) 

Milk-sugar (by volume) 

Milk-sugar (by weight) 

Cane-sugar (by weight) 

Malt-sugar 1 - (by weight) 

Barley Hour (by weight) 

Bice flour (by weight) 

Wheat flour (by weight) ...... 



Approximate 
Caloric Value. 



54 

20 

15 

12.5 

10 

G 

132 

10 

13 

80 

22 

72 
117 
117 
110 
102.5 
102.5 
102 



x Dextrimaltose, Mead, Johnson & Co. 



160 NUTRITION. 

To make malt soup : — 

Cold water 666 parts 

Milk (4 per cent, fat) .333 parts 

White flour 50 parts 

Malt extract (Loefflund's) 100 parts 

Mix flour and water and bring to boil. Add malt extract, stirring constantly, 
and bring to boil. Lastly add the milk, stirring constantly. Bring to boil three 
times, in the mean time cooling it off quickly by standing it in cold water. 

Eight level teaspoonfuls of starches or sugars are approximately 1 ounce in 
weight. 

The formulas on following page are based on the studied requirements 
of an infant of normal bodyweight, which is approximately 45.5 calories for 
each pound weight; hence an infant weighing 7 pounds requires 318 calories 
in twenty-four hours. 

This method is useful in controlling the feeding of infants who are not 
gaining in weight. We can increase the calories up to the required 
physiological standpoint, so that this method is in some respects similar to 
the percentage method advocated by Botch and others. 

Formula No. 1 (for an infant from birth to three weeks old, weighing 
about 7 pounds, requirement 318 calories) : — 

IJ Whole milk 13 ounces 

Hot water 12 ounces 

Dextrimaltose . . 4 drachms 

Mix thoroughly and heat in a saucepan until steam rises. Continue steaming 
at same temperature, five minutes. Divide into ten bottles of 2% ounces each. 
Feed every two hours. Insert large stoppers of non-absorbent cotton in the necks 
of the bottles. Place in a refrigerator, but not on ice. Warm before feeding by 
placing bottle into a deep saucepan of hot water until the food reaches body 
temperature. 

Formula No. 2 (for an infant from three weeks to six weeks old, weigh- 
ing about 8 pounds, requirement 364 calories) :■ — 

Ifc Whole milk 14 ounces 

Hot water 10 ounces 

Dextrimaltose 6 drachms 

Divide into eight feedings of 3 ounces each. Feed every three hours. 

Formula No. 3 (for an infant from six weeks to two months old, 
weighing about 10 pounds, requirement 455 calories) : — 

I£ Whole milk 17 ounces 

Hot water 15 ounces 

Dextrimaltose 1 ounce 

Divide into eight feedings of 4 ounces each. Feed every three hours. 

Formula No. 4 (for an infant from two to four months old, weighing 
about 11 pounds, requirement 500 calories) : — 



CALORIC FEEDING. 



161 



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1G2 NUTRITION. 

B Whole milk 19 ounces 

Hot water 16 ounces 

Dextrimaltose . . ; 1 ounce 

Divide into seven feedings of 5 ounces each. Feed every three hours. 

Formula No. 5 (for an infant from four to six months old, weighing 
about 12 pounds, requirement 546 calories) : — 

IJ Whole milk 22 ounces 

Hot water 14 ounces 

Dextrimaltose 1 ounce 

Divide into six feedings of 6 ounces each. Feed every three and one-half hours. 

Formula No. 6 (for an infant from six to nine months old, weighing 
about 14 pounds, requirement 637 calories) : — ■ 

I£ Whole milk 26 ounces 

Hot water 14 ounces 

Dextrimaltose 1 ounce 

Divide into five feedings of 8 ounces each. Feed every four hours. 

Formula No. 7 (for an infant from nine to twelve months old, weigh- 
ing about 17 pounds, requirement 773 calories) : — 

I£ Whole milk 35 ounces 

Hot water 5 ounces 

Dextrimaltose 6 drachms 

Divide into five feedings of 8 ounces each. Feed every four hours. 

Diet for a Child from One Year to Fifteen Months. 1 
The change from human milk to cows' milk sometimes causes gastro- 
intestinal derangement. For this reason a careful supervision of the stools 
and general comfort of the infant is required. Knowing the tendency of the' 
hard rubber curd of cows' milk to develop dyspeptic symptoms, it is advisable 
to give a dose of castor oil once every three or four days to eliminate stag- 
nant residue of food. Many infants show a tendency to constipation when 
cows' milk is fed. Such infants should receive large quantities of water, 
orange juice, or prune juice to stimulate peristaltic action. A small saucer 
of indian meal, Scotch oats, or corn muffin with butter will help to regulate 
the bowel. Expressed beef juice, 1 ounce given daily, is well borne and will 
exert a mild laxative action. 

Table No. 24. 

6.00 a.m. Milk, 8 ounces (if consti- 12.30 p.m. Beef or chicken broth with 

• pated give Horlick's toast crumbs. 

malted milk, 3 teaspoon- Expressed beef juice over 

fuls in 8 ounces of water ) . baked or mashed potato. 

Zwieback or biscuit. 4.30 p.m. Apple sauce or juice of 

9.30 a.m. Saucer of farina, hominy, or orange. 

cream of wheat. 6.00 p.m. Cup of junket. 

Cup of milk. Cup of milk. 

Biscuit. 

1 In the chapter on "Weaning," I have already described in detail another 
method of substitute feeding for a child about 1 year old. 



DIET FOR A CHILD FROM ONE AND ONE-HALF TO TEN YEARS. 



1G3 



Table No. 25. 
Diet for a Child from Fifteen to Eighteen Months. 



6.00 a.m. Milk and crackers. 

9.00 A.M. If constipated: prune jelly, 
apple sauce, or orange 
juice. 
Add 1 teaspoonful of dex- 
trimaltose to each cup of 
milk. 

9.30 a.m. Saucer of hominy, farina, 
Scotch oats, or cream of 
wheat. 
Cup of milk. 



12 Noon. 



3.30 p.m. 



0.00 p.m. 



Eight ounces of beef, lamb, 
or chicken broth, thick- 
ened with farina, sago, or 
homemade noodles. 

Coddled egg, alternate days; 
steamed rice with ex- 
pressed beef juice. 

Apple sauce. 

Cup of milk or malted milk. 

Zwieback or biscuit. 

Cup of custard, junket, or 
steamed rice. 

Cup of milk. 

Biscuit. 



Table No. 26. 
Diet for a Child from Eighteen Months to Three Years. 



6.30 a.m. Orange juice, 

Apple sauce, or 

Prune jelly. 
7.30 a.m. Warm milk, 8 ounces; 

Mellin's Food, 1 teaspoon, or 

Eskay's Food, 1 teaspoon; 

Zwieback or cracker, with 
butter. 
11.00 a.m. Farina, 

Hominy, 

Cream of wheat, 

Oatmeal, or 

Grape-nut, scalded with hot 
milk; in addition, a cup of 

Warm milk, 6 ounces. 
2.00 p.m. A soup, a meat, a vegetable, 
and a cracker. 

Beef or chicken soup, thick- 
ened with split peas, sago, 
rice, or farina. 

Drink of water 



Clear broth, with yolk of 
egg, or one or more ounces 
of expressed beef blood. 

Oyster or clam broth, 

Joint of chicken, 

Broiled halibut, 

Raw scraped steak, 

Chicken jelly, or 

Calf's-foot jelly (without 
wine flavor ) . 

Baked potato, with butter; 

Spinach, or 

Carrots. 
6.00 p.m. Crust of bread or zwieback. 

Warm milk, with white of 
egg; or 

Cocoa. 

Junket, custard, corn starch, 
tapioca, or farina pudding, 
with each meal. 



Diet for a Child from Three to Ten Years. 



A child of 3 years, excepting in rare instances, should not be fed of tener 
than three times a day. The best time for feeding is : morning meal, 7 to 
8 a.m.; noon meal, 12 to 1 p.m., and evening meal, 5.30 to 6.30 p.m. 

In rare instances fruit or a cup of milk may be allowed between the 
noon and evening meal. In the majority of cases five hours are required 
to fully digest the food given. 



1G4 



NUTRITION. 



The morning meal should consist of a fruit, a small dish of cereal with 
cream, a cup of milk, and a piece of toast or crackers. 

The noon meal should consist of a plate of soup, a small portion of meat, 
a small potato, a vegetable, bread, or crackers, or stale sponge cake, water. 

The evening meal should consist of an egg or pudding, a cup of cocoa 
or milk, crackers or bread with butter or honey. 

It is safer to give a light meal 1 in the evening rather than load the 
stomach with heavy food. The American custom of eating dinner at night 
should not be applied to children. 

That milk is very absorptive is well recognized. It is a bad precedent 
to store it away in refrigerators, unless it is placed in sealed jars, apart 
from foods which exude odor. 

Selection can be made from the following dietary : — 

Table No. 27. 



MORNING MEAL. 



Fruit- 
Raw, stewed, or baked apple. 

Grapes. 

Grapefruit. 

Oranges. 

Cherries. 

Peaches. 

Banana. 

Stewed prunes. 
Cereals — ■ 

Hominy. 

Oatmeal. 

Farina. 

Force, or 

Wheat Flake Celery Food. 



Cereals — 

Shredded wheat. 

Cream of wheat. 

Wheaten grit. 

Arrowroot. 

Cerealine. 

Yellow Indian meal. 

White indian meal. 

Wheat flakes. 
Buttered toast. 
Albert cakes. 
Zwieback. 

Vienna bread and butter. 
Egg in any form. 



NOON MEAL. 



Meat or chicken soup, thickened with 

lentils, peas, split peas, sago, farina, 

rice, or egg. 
Meat — 

Broiled chop, steak, or fish. 

Chicken. 

Stewed tripe. 

Sweet-bread. 

Raw scraped beef. 

Roast beef. 

Ham or bacon. 



Lamb. 

Bone marrow. 
Baked or mashed potatoes, spinach, peas, 

beans, tomatoes, cauliflower, carrots, 

asparagus, rhubarb, cranberries, or 

celery. 
Apple cider, buttermilk, kumyss, seltzer, 

lemonade, or very weak tea. 
Stale sponge cake. 
Lady fingers. 
Nuts. 



1 Horlick's Food Co. makes a malted milk lunch tablet, coated with chocolate, 
that is nutritious and digestible. They are especially indicated when small meals 
should be given. 



DIFFICULT FEEDING CASES. 1G5 

EVENING MEAL. 

Crackers and milk. Calf's-foot jelly without wine. 

Custard. Junket. 

Cornstarch pudding. Oysters. 

Corn muffins. Boiled, scrambled, or poached eggs. 

Farina pudding. Cream of barley. 

Milk toast. Cream of rice. 

Tapioca pudding. Cocoa and milk. 

Chicken jelly without wine. Toast or crackers. 

Articles of Food Which Should be Forbidden Until After the Tenth to 
Twelfth Year. — Fruit: All dried fruits (with the exception of prunes), 
preserved fruits, fruits out of season, over-ripe fruits or under-ripe fruits. 

Meats. — Pork, sausages, kidneys, duck, and goose. 

Vegetables. — Cabbage, radishes, cucumbers, turnips, and eggplant. 

Drinks. — Coffee and ice-cream soda. 

All candies, pies, and salads must be forbidden. 

Difficult Feeding Cases. 

If vomiting or eructations follow the use of whole milk, skim off the 
cream and use the skimmed milk in the same dilution as w r e formerly used 
the whole milk. If after changing from whole milk to skimmed milk the 
same condition continues, sugar should be discontinued. If the weight 
remains stationary and the general symptoms are good, we must increase 
the carbohydrate. For an infant under six months, the addition of V 2 to 1 
drachm of malt-sugar to each feeding will, if properly metabolized, increase 
the weight. If the infant is over six months, the addition of malt-soup or 
malt extract in % to 1 drachm doses to each feeding will increase the weight. 
In like manner a saucer of farina, hominy, or oatmeal steamed with water 
and served with 1 teaspoonful of malt-soup will increase the weight. If 
loose bowels and foul-smelling stools exist, fat-free milk should be fed. It is 
in this class of cases the virtues of Finkelstein's eiweiss milch will be noted. 

A study of the infant that does not assimilate its food requires a. de- 
tailed examination of the skin to see if an eczema is present. We should 
also study the muscular development to see if the muscles are flabby; note 
perspiration. The anus and buttocks inspected for excoriation and ery- 
thema; likewise the mouth examined for stomatitis. The tongue should be 
lifted to see whether or no the fraenum is adherent. The body weight should 
be taken, the heart and lungs examined. The presence or absence of dis- 
tention of the abdomen, the size of the liver, and special symptoms, such as 
vomiting, colic, and the frequency and character of stools, should be noted. 
The general comfort of the baby, whether restless or quiet at night, and its 
condition after taking the feeding are important guides. Thus only can we 
interpret the condition, and give intelligent advice. 



1G6 NUTRITION. 

Some infants have gastric disturbance with milk in any of its dilutions. 
This applies to fat-free milk, to diluted whole milk, or diluted cream. In 
such cases the alkaline milk, malt, and wheat modification, known as Keller's 
malt-soup, will usually be tolerated. Try feeding 4 ounces of malt-soup every 
three hours. If it agrees, increase 1 ounce each day until ounces are given 
at each feeding. 

KELLER'S MALT SOUP. 

Take of wheat flour 2 ounces and add to it 11 ounces of milk. Soak the flour 
thoroughly and rub it through a sieve or strainer. 

Put into a second dish 20 ounces of water, to which add 3 ounces of malt 
extract; dissolve the above at a temperature of about 120° F., and then add 2Y 2 
drachms of 11 per cent, potassium bicarbonate solution. 

Finally, mix all of the above ingredients and boil. This gives a food contain- 
ing: albuminoids, 2.0 per cent.; fat, 1.2 per cent.; carbohydrates, 12.1 per cent. 
There are in this mixture 0.9 per cent, of vegetable proteins. 

FLOUR-BALL FEEDING. 

The old-fashioned flour-ball is a valuable adjunct in malnutrition. A 
teaspoonful of the flour added to equal quantities of milk and water is easily 
assimilated and will be tolerated by very feeble infants.. 

In a dyspeptic infant suffering with frequent vomiting and atrophy due to 
the loss of food, the addition of 1 and later 2 teaspoonfuls of baked wheat-flour 
to each feeding was followed by an increase in weight, comfortable nights, yellowish, 
well-digested stools, and general improvement. After one month the gain in weight 
was over 1 pound. After two months of such feeding the infant was able to assimi- 
late other starchy foods, such as arrowroot and cornstarch. 

Flour-ball food is known commercially as imperial granu'm. It is made 
as follows: — 

Tie 3 or 4 pounds of wheat-flour in a muslin bag or several layers of 
cheesecloth, drop into boiling water, and boil for five hours. Eemove from 
the water, and bake in an oven until hard and dry. After cooling it is 
broken open, the rind rejected, and grated into a powder. 
An infant one month old should receive : — 

Milk 1 ounce 

Water 2 ounces 

Flour-ball / 2 teaspoonfuls 

Feed every two to three hours. 

For an infant six months old : — 

Milk 4 ounces 

Water 4 ounces 

Flour-ball 1 teaspoonful 

Dextrimaltose 1 teaspoonful 

Feed every four hours. 

Bub up the grated flour-ball with a little water ; gradually add the full 
quantity, the milk, and the dextrimaltose. Heat until the steam rises. 



DEXTRINIZED FOOD. 167 



Dextbinized Gbuels. 



Method of Dextriniziiig.— Prepare the wheat, barley, oatmeal, or rice 
flour by adding a tablespoonful of the same to a pint of water, adding a 
pinch of salt, and boiling the same for from fifteen minutes to one hour. 
This will make a gelatinous solution, and hence the name of barley jelly, 
rice jelly, oatmeal jelly, or wheat jelly. We allow this jelly to cool, and 
when cool enough to be tasted we can add a diastase, such as cereo ; or taka- 
diastase, made by Parke, Davis & Co. ; or the Forbes diastase. When a 
small quantity of this diastase is added to the jellies above mentioned, they 
lose their thickness, and become very thin. They can easily be strained 
through cheesecloth, and some water added to make up for the loss by 
evaporation during the boiling. This jelly, or gruel, as it is sometimes 
called, made from either barley, rice, wheat, or oatmeal, is to be used with 
the milk after the diastase is added. In certain diseases where milk is not 
well borne, such as dyspepsia (dyspeptic vomiting), or in summer complaint, 
where the giving of milk is prohibited, feeding with dextrinized gruels for 
several days will be found not only very useful, but very healthful. In 
making this dextrinized gruel, small particles will be seen floating, which 
settle out upon standing. These particles consist of the cell walls and the 
proteins of the cereal, and cut the curds of the milk into fine pieces, 
when the curds begin to shrink under the combined action of rennet and 
acid. In using this diastase we aim at breaking up the tough curd in cows' 
milk by purely mechanical means. 

Homemade Diastase for Dextrinizing Food. — Henry D. Chapin 1 de- 
scribes a simple decoction of diastase made as follows: "A tablespoonful 
of malted barley grains is put into a cup, and enough cold water added to 
cover it, usually two tablespoonfuls, as the malt quickly absorbs some of 
the water. This is prepared in the evening and placed in the refrigerator 
overnight. In the morning the water, looking like thin tea, is removed 
with a spoon or strained off, and is ready for use. About a tablespoonful of 
this solution can be thus secured, and is very active in diastase. It is suffi- 
cient to dextrinize a pint of gruel in ten to fifteen minutes." 

During the summer, in the critical cases of summer complaint in 
which subnormal digestion existed, the author has seen very good results 
follow the administration of any and all of the malt extracts now in our 
market. Frequently the administration of a half-teaspoonful of malt extract 
to an infant immediately before feeding was not only relished by the infant 
on account of the pleasant taste of the malt, but certainly aided in the 
assimilation of the food. Earely was more than three teaspoonfuls of malt 
ordered during twenty-four hours. Such preparations as maltine give very 
good results. The malt extract has a very pleasant flavor and is well borne. 



Journal of the American Medical Association, July 14, 1900. 



1G8 NUTRITION. 

Frequently, when expense proved an important item, sufficient dex- 
trinization of foods could be procured with these malt preparations above 
cited. 

Nutritional Disturbances. 

Weight Disturbance (Mild). — There are four clinical conditions, ac- 
cording to Finkelstein's classification, in which disorders of nutrition and 
faulty metabolism occur. First is the mildest form of intestinal disturb- 
ance in which we find weight fluctuations. Tn spite of the food being suffi- 
cient in quantity, there is no regular gain in weight. In addition to the 
fluctuation of weight, the temperature varies, the appetite is poor, and the 
food tolerance is lessened. 

"When a very rich cream mixture with high fat content is given, the 
excess of fat acts as an irritant and causes the symptoms of fat indigestion. 
These are chiefly soap stools and an increased ammonia output in the urine. 
Unless this condition is corrected by lowering the percentage of fat, symp- 
toms pointing to disturbance in the digestive tract will appear. 

Dyspepsia (Moderate). — In dyspepsia, the moderate form of weight dis- 
turbance, we have thin, greenish stools containing mucus. The loss in weight 
may not be marked. There may be vomiting and a slight elevation in tem- 
perature. Constipation, obstinate and difficult to relieve, exists. As the 
condition is caused by excessive fat- feeding, the treatment consists in reduc- 
ing the fat, and giving malt-sugar or malt extract to overcome the constipa- 
tion. Restorative treatment, chiefly fresh air, or change of air if possible, 
will aid in stimulating this faulty metabolism. 

The prime cause of dyspepsia is overfeeding. The great tendency to 
have large gains in weight has led many to prescribe high fats and ex- 
cessive quantities of carbohydrate, chiefly sugar. This excess of sugar will 
in time give rise to symptoms of vomiting and grass-green, diarrhceal stools. 
The abdomen is distended and there is a slight rise in temperature, usually 
between 100° and 101°. The excessive sugar feeding usually results in 
eczema of the face or scalp. There is marked irritation and erythematous 
redness around the anus. The tolerance for food is greatly reduced. Finkel- 
stein believes that when- the fat content of the food is high the excess of fat 
causes the lowering of the tolerance for sugar. The condition is frequently 
found in infants fed on condensed milk. Herein we have a distinct sugar 
disturbance, colic due to excessive fermentation, and flatulence. If this 
condition is neglected and the food elements not corrected, serious results 
will follow. 

An infant 3 months old, gaining in weight, with yellow stools, was suddenly 
deprived of its mother's milk and weaned. It was fed on cows' milk, 3 ounces; 
sterile water, 3 ounces; and malt-sugar, % teaspoonful, every three hours. After 
three days, vomiting, curded stools, and flatulence were noted. The diagnosis of 
dyspepsia was made. The formula was changed to skimmed milk, 3 ounces; sterile 



MALNUTRITION. 1G9 

water, 3 ounces; and malt-sugar, % teaspoonful. The symptoms appeared milder, 
but continued until the sugar was stopped, and equal parts of sterile water and 
skimmed milk were given. After one week ^ teaspoonful of Loefflund's malt ex- 
tract was added to every other feeding. In two weeks the formula was increased 
to skimmed milk, 4 ounces; sterile water, 3 ounces; and malt-sugar, y 2 teaspoonful. 

The third stage of nutritional disturbance is decomposition (severe), in 
which the most important symptom of malnutrition is atrophy. This is 
described elsewhere in extenso. 

The fourth stage of nutritional disturbance is called intoxication. 
Finkelstein proves that it is not the bacteria, but a failure of metabolism 
caused by an excess of sugar, and that milk-sugar can of itself produce this 
intoxication. The removal of sugar from the food is followed by a cessation 
of all s3 r mptoms. This condition is described elsewhere in detail. 

Milk Idiosyncrasy. 

In former editions of this book milk idiosyncrasy has been described. 
The reason for this non-tolerance of milk has proven very interesting. The 
physician must study the milk formula and learn therefrom which com- 
ponent of the food causes the distuibance. Is it a high fat content, as in 
cream feeding; or, is it a high sugar content? if so, try to remedy the 
formula by a reduction of fat, or a reduction of sugar, and in some instances 
to give the stomach absolute rest for twenty-four to forty-eight hours. This 
should be done to allay gastric irritation. In this class of cases malt-soup 
may be used to advantage. In some cases it may be well to feed 1 ounce of 
food every two hours, for twenty-four hours, and gradually increase the 
quantity from day to day until several ounces, at one feeding, are given. As 
we increase the food, the interval between feedings must be lengthened. 
Instead of two-hour intervals, three- or four- hour intervals may be demanded. 
The diagnosis of true milk idios} T ncrasy should not be made until after a 
thorough study of the real nature of the disturbing element, and then only 
if no form of milk — its dilutions or modifications — can be tolerated. 

Malnutrition" (Marasmus). 

When constipation exists and the infant does not assimilate its food 
as evidenced by stationary weight, the addition of 1 to 2 teaspoonfuls of 
Loefflund's malt-soup extract to each feeding will improve this condition. If, 
however, no gain in weight is noted, then Loefflund's malt-soup feeding may 
be tried. 

Vomiting. — When gastric irritability occurs and there is vomiting and 
curded stools, the substitution of a light food for a few days to one week is 
indicated. Such food should be condensed milk, 1 teaspoonful, and hot water, 
6 ounces, every three hours. If vomiting ceases, then increase to 2 teaspoon- 
fuls of condensed milk and 8 ounces of hot water. 



CHAPTEE IV. 

PERCENTAGE FEEDING. 

It is now many years since the Walker-Gordon milk laboratory was 
established in New York. Their method of feeding infants is based on 
mixing the ingredients in such combination that when combined they 
should resemble certain chemical' formulae of breast-milk at various ages. 

Theoretically the percentage feeding advocates are correct; practically 
we cannot successfully feed infants according to definite percentages. Daily 
variations are important, just as the variations in the human breast occur. 
The simpler the formula, the less chance of contamination. Blanks are 
given the physician, which are filled out according to the individual re- 
quirement. The age and weight are noted. Fat, sugar, protein, and water 
are prescribed in percentages. We are, therefore, able to state that the food 
ordered contains a definite percentage of fat, sugar, caseinogen, and lactal- 
bumin. The same is also true regarding the heating of food. We can pre- 
scribe the food sterilized, pasteurized, or raw. Many changes can be made : 
we can increase or decrease the fat; the same is true of sugar and protein. 

The quantity of food prescribed depends on the requirements of each 
infant. Some infants can take 3 ounces at one feeding, while others appear 
satisfied after taking 2 ounces of food. 

Examples. — For an infant at birth: — 

Fat 2.00 

Sugar 5.00 

Protein 1.00 

Lime-water . 5.00 



► Formula I 



Formula II 



Milk, raw or pasteurized. Two ounces to be given every two hours. 
If the infant thrives, the ingredients may be increased; also the quan- 
tity at each feeding : — ■ 

Fat 2.50 

Sugar 6.00 

Protein 1.00 

Lime-water . 5.00 

Later, if conditions warrant it : — 

Fat 3.00 

Sugar 6.00 

Protein 1.50 

Lime-water 5.00 



Formula III 



In this manner we can gradually increase the percentage of ingredients 
until whole milk is ordered. When abnormal conditions prevail — such as 
loose bowels — barley water may be substituted for the sterile water. 
(170) 



PERCENTAGE FEEDING. 171 

Successful percentage or laboratory feeding will only be accomplished 
when the physician is willing to supervise the products of metabolism and 
increase or decrease the ingredients demanded by individual symptoms. For 
example : hard, dry, saponified stools require lower percentage of fat ; a 
very anaemic condition, more fat and protein; a restless, hungry infant, 
immediately after feeding, a larger quantity of all ingredients. 

It is impossible to make an emulsion like milk from its component 
parts by a synthetic process. Let it, therefore, be distinctly understood that, 
once a milk emulsion is broken up, as is done in centrifuging milk and 
removing the cream, mixing the whole will never restore the uniformity 
of the emulsion that existed prior to this division. 

In domestic modification, of course, the same care must be taken to 
secure clean, pure milk and cream from healthy, well-kept cows. This is 
quite possible now in New York, and is becoming easier each year, as more 
attention is being given to infant-feeding and greater demand is being made 
for a pure milk supply. Pasteurization is as readily done in the nursery as 
in the laboratory. Accurate measurement of quantities and cleanliness of 
vessels and feeding-bottles are equally possible and, in my experience, quite 
as certain at home as in the shop. 

Clinical experience has demonstrated the fact that some children will 
thrive on condensed milk in spite of faulty hygiene, while others will not 
thrive in the best environment with the best form of feeding; again, some 
children will thrive on modified milk; others will not. Some cases seen by 
the author suffered with intense constipation, having clay-colored stools. 
In one instance, in which two children in one family were constantly fed 
on modified milk of varying proportions, the formulae were changed at least 
a half-dozen times, with the usual increase of fat and sugar and lowering of 
the proteins, and in spite of this fact, after repeated trials, and no benefit, 
this feeding method was abandoned. A child recently seen by the author 
did not gain 1 ounce in four months. This was one of the reasons that 
prompted the family to change both the ph}'sician and the food. The child, 
about 2 years old, was very pale, restless at night, quite peevish during the 
day, and decidedly backward in development. It could neither speak nor 
walk, although the teeth were well developed. From the time the modified 
milk was discontinued, and a nitrogenous diet given, the infant improved, 
and from last reports is quite well developed. 

Do not let us blindfold ourselves with the belief that an infant is 
thriving unless it shows a regularity in the increase of iveiglit, sleeps 
well at night, for at least from six to nine hours continuously, and, above all, 
assimilates its food, as evidenced by regular, unaided movements of the 
bowels; such movements should be once or twice in tiuenty-four hours, have 
a yellowish- white color, and a mustard-lil'e consistency. If the stool is hard 
or lumpy or pasty, Wee putty, then it is certainly abnormal, and shows im- 



172 NUTRITION. 

proper food. The same is also true if the stool contains white, cheesy curds, 
showing a fat indigestion. In one infant, which had taken modified milk 
continuously for seven months, an obstinate constipation was only relieved 
after full doses of codliver-oil and extract of malt were given for several 
weeks — aided by massage, besides changing the diet. 

It is, therefore, very necessary to continually watch the baby, and when 
abnormal conditions such as anaemia prevail, it is wise to give restoratives 
for a long period in addition to the food. Note if the food is deficient 
in its nutritive elements, and, if so, change the formula so as to adapt it to 
the baby. Do not give medicine when the quality or quantity of food is 
deficient. Remedy the food first; then, if not satisfied, give medication. 

An unusual pallor of the skin, and also of the conjunctival mucous 
membrane, has frequently been noticed in modified-milk babies. In one 
instance an extreme leucocytosis was noticed, for the treatment of which 
iron was given. An examination of a drop of blood showed a diminution of 
the red blood-corpuscles and an excess of the white blood-corpuscles. A 
decided hsemic murmur was noticeable in the vessels of the neck in a child 
2 years old which had been fed continually on modified milk. 

Craniotabes, softening of the cranial bones, as well as very late closing 
of the anterior fontanel, have also been observed in some children fed with 
this form of food. 



CHAPTER V. 
OTHER SUBSTITUTE FOODS. 

Goats' Milk. 

My experience with goats' milk has been rather good. The following 
case will serve to illustrate the manner in which goats' milk was used : — 

An infant, seven months old, was seen by me in consultation. She could not 
digest cows' milk, but suffered vomiting, with intestinal colic, and had cheesy and 
curded stools. When goats' milk was given in the sUme quantity as cows' milk, the 
acute indigestion subsided. 

In a second case, an infant, one month old, vomited whenever cows' milk was 
given, and suffered with dyspeptic catarrh. The symptoms subsided when the infant 
was put to the breast of a wet-nurse. After several months wet-nursing the infant 
was again given cows' milk, and again the symptoms returned. As we could not 
procure a wet-nurse, goats' milk diluted with rice water, using four ounces of 
goats' milk with four ounces of rice water, and one teaspoonful of sugar, was given. 
The child, six months old, was fed once every three hours. After one week's feeding 
we increased the quantity of goats' milk to five ounces and decreased the rice water 
to three ounces. When the child was nine months old pure goats' milk, pasteurized 
for ten minutes at a temperature of 158° F., was fed, with very satisfactory results. 
The child gained in weight and had yellowish stools. 

Barbellion 1 has for years been an ardent advocate of the introduction 
of goats' milk for infants and invalid diet. He describes tests which show 
that the coagulum is soft and very soluble, like that of human and asses' 
milk, while the coagulum from the cows' milk is more compact and difficult 
to digest. Comparative tests with gasterin showed that, while cows' milk 
was scarcely affected by it during twenty hours, human, goats', and asses' 
milk were completely digested. 

He reports a number of cases showing the remarkable manner in which 
infants thrive on goats' milk. The Academie voted in favor of his conclu- 
sions as to the advisability of establishing numerous goat milk depots 
throughout the city. One of the principal advantages of the goat for this 
purpose is that it is refractory to tuberculosis. 

Buttermilk Feeding. 

A very elaborate paper on the subject of buttermilk feeding, by Dr. 
Teixeira de Mattos, of Eotterdam, has been published. 2 • He cites de 



1 Goats' Milk for Infant Feeding. Barbellion (Paris). Bulletin de 1' Academie 
de Medecine (Paris). 

2 Jahrbuch fiir Kinderheilkunde, January, 1902. 

(173) 



174 NUTRITION. 

Jager, who published a paper 1 recommending this form of feeding; 
Karger; Houwing, 2 and private and public reports of Schlossmann, 
Heubner, Soltmann, Finkelstein, de Mattos, and others. 

Buttermilk. — Take 1 quart (liter) of buttermilk; add 1 even table- 
spoonful of rice, wheat, or other flour desired (about 10 to 18 grams) ; heat 
the mixture over a small gas] fire, with constant stirring, until it has boiled 
up three different times (requiring about twenty-five minutes) ; then add 
2 or 3 tables poonf ids (about 70 to 90 grams) of cane sugar or beet sugar. 
It is better to use new enameled ware or agate ware for preparing this food. 
The food as above prepared assumes a yellowish color. 

It is necessary to have wide mouths for the bottles, as the food coagulates 
and gets lumpy, in which event it would require occasional shaking to bring 
the thickened portion to the proper consistency. 

Bulgarian Milk. — Milk soured with either a pure culture of the lactic 
acid bacillus, or tablets containing the Bulgarian bacillus, must not be con- 
founded with ordinary buttermilk. By the action of the lactic acid on the 
casein of the whole milk, one transforms the casein into a soluble casein 
lactate. 

How to Prepare. — Boil the milk and, when cool, skim off the skin that 
rises. To one quart of boiled milk add one teaspoonful of pure culture 
of the lactic acid bacillus, or one tablet containing such bacillus, made by 
the Fairchild Brothers & Foster, or by Parke, Davis & Co. Set this 
inoculated milk in a warm place for twenty-four to forty-eight hours. 
The lumpy mixture must then be thoroughly shaken, and if of a thick, 
creamy consistency must be placed in a refrigerator to retard further 
souring. 

Graanboom, in his book on "Diseases of the Digestive Tract in 
Children" (1901), states that he also is very much impressed with the 
value of buttermilk as an infant-food. ' 

De Mattos states that children so fed for a period of six to eight 
months show signs of rickets or late dentition, although they look well 
and appear to be well nourished. Whether other methods are worse he 
does not state. 

Lactic acid was never found in the urine of infants fed either with 
lactic acid or salts. This series of experiments was made by de Mattos, 
and the results were corroborated by Houwing. 

The amount of lactic acid present in buttermilk has been carefully 
studied. Bobertson, a chemist, found it to be : — 

Minimum 0.09 per cent. 

Maximum 0.45 per cent. 

x Nederlandsch Tydschrift voor Geneeskundigebladen, October, 1895. 
2 Centralblatt fur Gynakologie, 51, 190. 



BULGARIAN MILK. 175 

De Jager believes that good buttermilk does not contain more than 0.5 
per cent, of free lactic acid. 1 These are, however, not absolute and positive 
data, but really individual hypotheses. 

Contrary to the ideas of Munk, Uffelmann, and Ewald (who fear the 
use of food containing lactic acid), de Mattos has found that chronic 
enteritis and gastric complaints soon improve when an exclusive buttermilk 
feeding is resorted to. Hayem and Lesage regard lactic acid as entirely 
innocuous for nurslings. According to the above-named investigators, lactic 
acid is not toxic for infants. They gave experimentally 15 to 20 grains in 
divided doses, mixed with sugar, without seeing any detrimental results. 
Jaworski 2 found no trace of lactic acid in an infant's stomach one hour 
after administering it.. 

Eiel maintains that lactic acid improves digestion, while Duclaux 3 
states that lactic acid is a valuable astringent. Heubner 4 found lactic acid 
in the stomach of two healthy infants (to the extent of 0.16 to 0.2 per cent.). 
Marfan (quoting Zotow) maintains that, when lactic acid is found in the 
stomach of infants, it is always a pathological factor. 

Buttermilk in its crude (raw) state is certainly antagonistic to other 
micro-organisms. This is due to the presence of lactic acid bacilli. Eaw 
cows' milk possesses bactericidal properties, but buttermilk is much more 
bactericidal. The latter, sterilized with the aid of steam, showed virulent 
typhoid bacilli nine da}'s after being inoculated with the same. In lion- 
sterilized buttermilk (raw state) virulent typhoid bacilli lost their virulence 
after two days, and when put into the brooding oven lost their virulence 
after twenty-four hours. The bacillus lacticus of Pasteur and Hueppe seems 
to be identical with the bacillus lactis aerogenes of Escherich, 5 which is 
found in the upper part of the small intestine. 

Jaworski found that pepsin is more readily secreted when lactic acid 
is given internally. De Mattos states that he has never met with a case of 
Barlow's disease among infants fed with buttermilk. 

Disagreeable symptoms are frequently encountered for the first few 
weeks while giving buttermilk. Such are frequent vomiting and diarrhoea. 
These are not contra-indications for feeding, and, notwithstanding the 
presence of the above-named symptoms, the feeding should be continued. 
If, however, the symptoms are very severe, then the administration of astrin- 
gents — such as bismuth, argent, nitrate, tannalbin, or ichthalbin— may be 
required for temporary relief. 

An important point is that in this form of infant-feeding the large, 



5 Nederlandsch Tydsehrift voor Geneeskimdigebladen, 1899, i, S. 945. 

2 Deutsches Archiv fur klinische Medicin, Bd. xxxvii, i. 

3 "Maladies de l'Enfance," tome ii, p. 000. 

4 "Jahrbuch fur Kinderheilkimde," 1891. 

5 "Die Darmbacterien des Sauglings/' Stuttgart, 1886. 



176 NUTRITION. 

thick, cheesy curds so commonly met with in dyspepsia and diarrhoeas in 
feeding with cows' milk are never seen. Children thus fed seem to with- 
stand the infectious diseases very well. A point worth noting is that when 
a child is more accustomed to buttermilk feeding the change to sweet milk 
will cause diarrhoea. 

When we find that the weight is not increased and we desire to change 
to sweet milk, the latter should be gradually added to the buttermilk in- 
stead of making a distinct change suddenly. 

duality of the Buttermilk. — This is the most important part of our 
subject. In securing our food we must be sure that we are dealing with 
honest dairymen whose sole object is to deliver what is demanded for weak 
infants. Stale combinations made by the use of left-over centrifugal milk 
or skim-milk or spoiled milk which cannot be used otherwise should be 
inquired into and rejected. 

Good buttermilk can be made from either whole milk or from cream. 
In Holland buttermilk is made by pasteurizing cream in Timpe's apparatus 
and then inoculating and buttering the same with a pure culture of lactic- 
acid bacillus. In order that raw milk will yield buttermilk a certain per- 
centage of acidity must be present. 

The usual precautions in milking (so-called modern stable hygiene) 
must be observed in securing milk to be used in making buttermilk. The 
milk should be received in sterile vessels and rapidly cooled, and should then 
be kept in cool cellars or ice-coolers having a low temperature (no higher 
than 15° or 20° C.) for eighteen to twenty-four hours. It is necessary to 
stir the milk occasionally. Eapidity of souring can be assisted by adding 
sour milk or by inoculating with a pure culture of lactic-acid bacilli. No 
definite rule can be laid down as to when buttering . takes place; empiric 
methods must decide this matter. This is due to the size of the vessel used 
and the influence of seasonal changes, and also the amount of churning it 
had received. Cows' milk which contains colostrum or which is bitter is not 
adapted for buttering. 

Butter should form in small, pin-head-sized particles in thirty to forty- 
five minutes. It is regarded as a mistake to have large particles of the size 
of a pea or larger, and dairymen look upon such buttermilk with suspicion. 
Buttermilk in general contains about 0.3 to 0.4 per cent, of fat.. 

Escherich states that the fermentation of milk is due to the splitting 
up of the milk-sugar, whereby lactic acid, 0, and C0 2 are formed in the 
intestine. 

Table No. 28, on following page, is instructive in showing the per- 
centage of acidity present and also the difference in fat. 



BUTTERMILK. 



177 



Table No. 28. 





Specific 
Gravity. 


Solids, 
Percentage. 


Fat. 


Acidity According 
to Soxhlet-Henkel. 


Sour milk before 
butteriug 


1.029 


11.40 


2.8 


18.1 


Buttermilk 


1.029 


9.60 


0.5 


16.1 



There is, therefore, a difference of 2 per cent, in -the amount of acidity 
present in favor of buttermilk. 

An important point is to overcome the lumps usually found as coarse 
coagula in buttermilk'. De Mattos advises adding flour — either rice, wheat, 
or lentil — or even some proprietary infant foods, according to the require- 
ments of the infant. 

This is merely given to hold the nocculi in finer form and to prevent 
their coagulation into lumps. Dyspeptic children with subnormal digestive 
powers should receive a minimal quantity; thus, an even tablespoonful, 
amounting to about 10 grams, will suffice. 

Addition of Sugar. — The quantity of sugar to be added must be reck- 
oned empirically; thus, 3 tablespoonfuls, about 90 grams, are required to 
each liter (quart) of buttermilk. Barely do we need more than 100 grams. 

Cane-sugar or beet-sugar serves best for sweetening. Sugar cannot be 
found in the urine nor in the faeces of infants fed on buttermilk to which 
sugar was added. 

The results which might be expected from using cane-sugar — such as 
diarrhoea, fermentation, sour eructations — are totally absent in using butter- 



milk feeding. 



Stools. — The average buttermilk-fed infant has no more than one or 
two stools daily. They are more or less solid in consistency and have an 
all- aline reaction. It would be incorrect to state that all children fed with 
buttermilk must have yellow stools. We know that even Uffelmann, in his 
studies of infant-stools, states that breast-fed infants show great variations 
from apparent normal stools and still thrive. We also know that bottle- 
fed infants reared on cows' milk have no definite hind of stool which we 
could call a standard stool. Still, the buttermilk-fed infant never has the 
coarse casein particles in the faeces that we see very frequently in the stools 
of infants fed on cows' milk. 

The bacteriological examination of the faeces made by inoculating 
gelatine plates with diluted faeces showed : — 

1. Liquefying colonies rendered Loeffler's nutrient gelatine strongly 
alkaline. Inoculated into bouillon, the latter remained clear, forming a 
skim on the surface. Milk was not coagulated by these micro-organisms. 



178 NUTRITION. 

They formed spores, generated II 2 S, and can therefore be identified as the 
bacillus butyricus of Hueppe. 

2. Non-liquef} dug colonies were inoculated into milk-sugar bouillon and 
left in the brooding oven over eight hours at 37° C. All tubes so treated 
were turbid on standing over night; this fact excludes the possibility of its 
being the bacterium coli. 

Other properties were found, such as : fermentation in milk-sugar 
bouillon, no skim forming on the bouillon; indol does not form in peptone 
solution (bacterium coli would form indol) ; milk turns sour but slowly; 
no NH 3 formation. 

From a study of the above properties we conclude : — 

1. Bacterium coli commune must be excluded. 

2. Bacterium coli lactici (Hueppe) (resp. bacterium lactis aerogenes, 
Escherich) must be identified. 

The lactic acid bacillus, found in boiled as well as raw buttermilk, loses 
its potency in the intestinal canal in the presence of the bacillus butyricus 
(Hueppe). The latter germ grows in overwhelming numbers and renders 
the intestinal contents rapidly alkaline. 

An interesting point is that, if the buttermilk' was originally very 
sour, the feces will be very alkaline, showing how weak the bacterium acidi 
lactici is. 

Feeding. — The writer has seen excellent results from buttermilk feeding 
in atrophic and marasmic children. As an article of diet during convales- 
cence after pneumonia and typhoid fever the results were encouraging. 

Quantity to be Fed.- — Buttermilk as above prepared should be fed 
exactly as would other milk. Four ounces, increased to 5 or 6 ounces, can 
be fed every 3 hours, or the interval may be prolonged to 3% or 4 hours. 
It will be necessary to coax the child in the beginning with this new form 
of feeding, owing to the difference in the taste of fresh milk and butter- 
milk. 

Lahmann's Vegetable Milk. 

In Europe, and recently also in our country, the feeding of infants has 
been enriched with a new product; thus, Dr. Lahmann believes that the 
great panacea is feeding infants with milk which he designates as ''vege- 
table milk." It resembles a thick jelly, and is made by Hewwel & Veithen, 
of Cologne. His theory consists, in brief, in substituting nuts and almonds. 
which are rich in albumin and fat, instead of cereals to dilute milk, his 
idea being that an emulsion which is digestible- and supposed to be rich in 
albumin is doubtless better than pure water or a thin starch paste. In 
order to add food salts, which are not supplied by this means, he extracted 
them from leaf vegetables, which are rich in food salts, and added some 
sugar syrup. In this manner he claims to have made a preparation which 
he states is chemically equal to human milk, and full of nutritive value. His 



CONDENSED MILK— CONDENSED CREAM. 179 

idea is that the interposition of plant-albumin (conglutin) particles, which 
coagulate with difficulty between the coagulating casein masses, would in- 
crease their digestibility by breaking them up, and that the digestion of the 
plant-albumin and oil, as well as of the sugar and food salts, would present 
no difficulty. 

Stutzer, of the University of Bonn, reports thus: The vegetable milk 
is distinguished from children's food by the absence of starchy substances. 
In common with Biedert's cream mixture, the vegetable milk contains con- 
siderable quantities of fat in an emulsified condition. It differs from the 
cream mixture in the way it is prepared, and in its other qualities. 

Chemical Analysis. 

Fat '. 34.72 per cent. 

Plant-casein and similar nitrogenous constituents. . 12.00 per cent. 

Sugar and plant-dextrin 31.02 per cent. 

Salts 1.64 per cent. 

Water 20.62 per cent. 

My own personal experience has been rather favorable with the use of 
the vegetable milk, inasmuch as an emulsion of almonds and nuts was used 
to dilute the curd of cows' milk. Thus, equal parts of vegetable milk with 
cows' milk were taken by an infant for several months, and it was very 
well assimilated. Isot only did the child gain in weight, but the bowels were 
in a fair condition, and the infant remained strong. 

Condensed Milk or Condensed Cream. 

Hundreds of infants are fed with condensed milk. This has its 
reasons : — 

1. The readiness with which condensed milk is obtained. 

2. The great cheapness of this article. 

3. The ease with which the feeding mixture can be prepared. 

Jacobi says that some manufacturers use pure cows' milk; others find 
it in accordance with the health of their bank accounts to use skimmed milk. 

Quantity of Sugar in Condensed Milk. — Milk sold in our city for im- 
mediate use contains about 12 to 15 per cent, of sugar. Milk to be kept for 
an indefinite time contains as much as 50 per cent, of sugar. These varia- 
tions show how serious it is to use the same quantity of condensed milk all 
the time and from different sources with such an enormous variation in the 
quantity of sugar. 

Kehrer — quoted by Jacobi — states,- regarding it, that it increases the 
formation of lactic acid. Fleischman states that it gives rise to thrush and 
diarrhoea; Daly, that it fattens them ( ?), but gives rise to rachitis. 

The worst specimens of rachitis and spinal rickets seen in my clinic 
are in condensed-milk babies. Our medical literature reports many cases 



180 NUTRITION. 

of apparent health in infants fed on condensed milk. It has led Des- 
sau, with a large experience with infants, to mention such a method, al- 
though he advocates cows' milk, properly modified, for continued use. 1 

In traveling, when good fresh cows' milk cannot be obtained, then I 
permit the use of condensed milk, but for a few days or for a week only, 
as on the ocean steamer, where cows' milk cannot be had. 

My experience among thousands of children seen in my Children's 
Service at the German Poliklinik and also at the service at the West- Side 
German Dispensary during these last fifteen years has been that children 
so fed have rickets ; that they are predisposed to the infectious disorders ; 
that they have less resistance and far less vitality, especially in combating 
such diseases as pneumonia or diphtheria; that they have tendencies to 
hernias and deformities, owing to the softer condition of their muscles and 
bones; that they invariably suffer with constipation, alternating with diar- 
rhoea; that their dentition is delayed, compared with other methods of 
hand feeding. Thus summing it up, I cannot approve of this method at 
all. 

Condensed cream will be lauded by the mother whose baby is well, and 
again the same food will be condemned by the mother of an infant whose 
rickety head, bones, and muscles are founded on an impoverished diet of 
condensed milk. We can account for the rickety child, but we cannot 
account for the healthy one on the same food. 

The directions on the tin of the Anglo-Swiss Condensed Milk Com- 
pany's Milkmaid Brand of condensed milk are, for new-born infants, add 
14 parts of water; as the child grows older, gradually use less water, but 
never less than 7 parts. 

On studying the clinical relationship of the component parts of con- 
densed milk, it is very apparent that, diluting the Eagle brand of condensed 
milk with 14 parts of water, we have but 0.7 per cent, of protein, 0.6 per 
cent, of fat, and 3.5 of sugar. The deficient bone-building and muscle- 
forming ingredients account for the rachitis which invariably results. 



1 See my paper on infant-feeding (read before the Society for Medical Progress, 
April 11, 1896), published in exienso in Pediatrics for July 15, 1896. 



CHAPTER VI. 
PROPRIETARY INFANT FOODS. 

Patent Foods. 

There are a great many infant foods in use at the present time. No 
one will question the large amount of foods sold. This is due to several 
reasons: First, because the laity have been educated to use them, when 
cows' milk or even when breast-milk, in rare instances, disagrees; second, 
physicians of large experience advocate the use of a great many patent foods. 
When disturbances in the stomach or intestines interfere with the proper 
digestion and assimilation of the proteins, then frequently the modification 
of the milk, by the addition of these foods, yields good results. In some 
instances where there is no appetite we frequently can stimulate an appetite 
by advocating the temporary use of these foods. 

In the large cities, where breast-milk is unobtainable for infants, these 
foods are frequently given. 

During the course of summer complaint, typhoid fever, or acute infec- 
tious diseases, I have frequently advised the use of diluted milk with several 
teaspoonfuls of a nutritious food, rich in barley malt. The objectionable 
features of patent foods consist in the ease with which they are procured, 
and the careless manner in which they are given. Thus, a large portion of 
the laity will follow the directions on the label of the box of patent food 
to the detriment of the child. Many a case of rickets or scurvy can be traced 
to ignorance in giving patent foods. We know, however, that there are some 
virtues in these patent foods, and to attribute all cases of rickets or scurvy 
to this one cause is wrong. Investigations made by the American Pediatric 
Society showed that a large number of children fed on sterilized milk suf- 
fered with scurvy. A great many facts must therefore be considered before 
condemning or praising one or all of the foods. Every physician knows 
that raw milk or milk warmed to blood heat possesses anti-scorbutic 
properties. When a given commercial food is added to raw milk, thoroughly 
mixed, and heated to blood heat or to a pasteurizing temperature, we still 
retain the virtues of the milk and increase its nutritive value with the aid 
of the foods selected. Roughly speaking, there are two kinds of infant foods 
on the market: (a) Infant foods to be used as adjuncts to fresh cows' milk. 
(b) Infant foods in which desiccated cows' milk is a constituent. 

These foods are commonly known as dried-milk foods, although in this 
class of foods milk solids constitute but from one-eighth to one-fourth the 

(181) 



182 NUTRITION. 

substance of the foods, the balance consisting of matter derived from 
cereals. In some of these foods the starch of the cereals is untransformed, 
and they may be termed farinaceous dried-milk foods. In others the starch 
of the cereals has been transformed into dextrin and maltose, and they may 
be termed dried malted milk foods. 

The group of infant foods used as adjuncts to cows' milk are either 
farinaceous foods, made from cereals and consisting largely of unconverted 
starch, or malted foods, also made from cereals, but having the starch 
transformed into soluble maltose and dextrin. As fresh cows' milk is, with- 
out doubt, the best generally available material for the artificial feeding 
of infants, the foods of the latter class, used for the modification of fresh 
cows' milk, are more in accord with physiological principles than are the 
dried-milk foods. 

Of the large number of infant foods that have been put on the market, 
it is my purpose to describe a few commonly known foods. In order to 
judge fairly of the nutritive value of an infant food and its resemblance 
to woman's milk, it is necessary to know its composition after its preparation 
for the nursing-bottle according to the directions of its manufacturer, and 
the analyses that accompany the following descriptions are of the foods 
prepared for use for infants six months of age as per directions on the 
packages. 

List or Infant Foods. 

The following list of infant foods is quite complete, although there are 
but four or five foods that are used in any quantity, the balance having 
a small demand : — 

Blair's Wheat Food (cereal food; baked wheat). 

Hubbel's Wheat (cereal food; baked wheat). 

Wampole's Milk Food (composed of predigested cereals, beef, and 
milk). 

Wyeth's Prepared Food (composed of malt milk and cereals). 

Just's Food (partially predigested cereals. To be used with milk). 

Malted Milk (malted and containing dried milk). 

Horlick's Food (predigested, to be added to milk). 

Mellin's Food (predigested, to be added to milk). 

Imperial G-ranum (baked wheat). 

Nestle's Food (composed of cereals partially predigested and dried 
milk). 

Lacto-Preparata (dried milk). 

Lactated Food (farinaceous with milk-sugar). 

Mammala (dried milk food). 

Kidge's Food (farinaceous). 



NESTLE'S FOOD. 183 

Peptogenic Milk Powder (to modify milk). 

Pegnin (also used to modify the casein of cows' milk). 

Zimmerman Barley Oat Food (cereal). 

Nutrico Food (cereal). 
• Lange's Tissue Food (a condensed milk). 

Hayes's Oat Food (cereal). 

Allenbury's Milk Food, No. 1 (predigested; prepared with water, con- 
tains dried milk) . 

Allenbury's Milk Food, No. 2 (predigested; prepared with water, con- 
tains dried milk) . 

Allenbury's Malted Food, No. 3 (partially predigested; prepared with 
milk). 

Benger's Imported (cereal and not predigested). 

Neave's Food, Imported (farinaceous). 

Eskay's Albuminized Food. 

Cereal Milk. 

Carnrick's Soluble Food. 

Diastased Farina. 

Coombs's Malted Food. 

Eobinson's Groats. 

Eobinson's Patent Barley. 

Chapman's Whole Flour. 

Scott's Oat Flour. 

Milkine. 

The published analyses of woman's milk show the great variability of 
its composition, especially as regards the percentage of proteins and fats. 
The analysis of woman's milk used in the following tables is by Dr. Luff, 
adopted as the standard by Cheadle. It agrees closely with Leed's analysis, 
excepting as to the fat, which is given by Luff as 2.41 per cent, and by 
Leeds as 4.13 per cent. ; the latter amount seems too large, as it exceeds 
considerably the published averages of a number of observers. 

Nestle's Food. 

Nestle's food is a farinaceous dried-milk food. According to the 
manufacturers, it is made of pure cows' milk, ground wheaten biscuit, barley 
malt, and cane-sugar. It is a form of modified milk. 

No cows' milk is to be added to Nestle's food — nothing but water. 

Upon examination, maltose, dextrin, and cane-sugar will be found to 
be its principal ingredients, amountirg to about 52 per cent, of the whole. 
The amount of lactose (G.57 per cent.) represents only that contained in the 
milk used in manufacture. 



For 3d Mo. 


6th Mo. 


9th M 


0.96% 


1.18% 


1.30' 


2.03 


2.50 


2.73 


1.7G 


2.16 


2.36 


3.22 


3.96 


4.33 


2.24 


2.77 


3.03 


0.74 


0.90 


1.00 


1.42 


1.75 


1.91 


0.19 


0.24 


0.26 


87.44 


84.54 


83.08 


100.00 


100.00 


100.00 


Reaction alkaline. 





184 NUTRITION. 

The directions for preparing Nestle's food for the nursing bottle, for 
infants six months of age, are as follows : — 

Place the required amount of food in the saucepan and add a sufficient 
amount of cold water to make a smooth, creamy mixture, then add the rest 
of the water, and boil for two minutes. 

Table No. 29. — Composition of Nestle s Food When Prepared for Different Ages. 

Analysis by Composition when Prepared 

Dr. Boyce W. Knight. According to Label Directions. 



Milk sugar 7.40% 

Maltose 15.60 

Dextrin 13.51 

Cane sugar 24.77 

Starch 17.31 

Fat 5.63 

Proteins 10.92 

Mineral matter 1.49 

Water 3.37 

100.00 



The total carbohydrate content of this mixture (12.57 per cent.) is 
considerably higher than the carbohydrate content of milk sugar (6.39 per 
cent.) of woman's milk. This, however, may be accounted for by the fact 
that the fat content (0.90 per cent.) is equally lower than the fat content 
of woman's milk (2.41 per cent.). 

It is claimed by the manufacturers that the value of the milk used in 
Nestle's food is not destroyed, as the condensing is done in vacuum, at a 
temperature not exceeding 130° F. 

When cows' milk disagrees and gastric symptoms such as fever, vomit- 
ing, and intestinal catarrh appear, the substitution of Nestle's food for 
several days will frequently relieve this condition. 

Horlick's Malted Milk. 

This is a dried milk food, said to be composed of pure, rich cows' 
milk combined with the extract of malted grains, and not to require the 
addition of milk, nor any cooking. The manufacturers claim that by 
their methods and apparatus the proteins are rendered very digestible 
and do not form large, irritating curds in the stomach. 

The directions for preparing the food for an infant six months old 
are to dissolve 3 to 4 heaping ieaspoonf uls in 4% to 6 ounces of water. 



CEREAL MILK. 235 



Table No. 30. 

Horliclc's Malted Milk. Woman's Milk. 

Water 86.29 88.51 

Salts 0.55 0.34 

Proteins 2.31 2.35 

Fat 1.24 2.41 

Carbohydrates 9.61 6.39 

This product is very nearly soluble in water, as its principal con- 
stituents . are the soluble carbohydrates — maltose, dextrine, and milk 
sugar. The drying process is said to be conducted very carefully in a 
vacuum, and hence the solubility and digestibility of the product, it is 
claimed, are not lessened. - 

The proteins are about the same as in woman's milk, but the fat is 
about three-fifths and the carbohydrates are about five-thirds as much as 
in woman's milk. 

When cows' milk causes continued constipation, the substitution of 
a bottle containing hot water 8 ounces, in which 4 teaspoonfuls of malted 
milk are dissolved, is indicated. It acts as a corrective, as the maltose 
has a laxative effect. 

Horlick's Food. 

Horlick's food is prepared from barley, malt, and wheat flour, and is 
designed to be used in connection with cows' milk, as a modifier. It is free 
from starch or cane sugar, and is completely soluble. 

When prepared with milk, as directed, it brings the carbohydrates in the 
form of maltose and dextrine to the proper standard, and at the same time 
acts upon the milk so that it is easily digested. 

In some cases food prepared as above has a tendency to constipate. In 
such cases the substitution of malted milk for the first morning bottle will 
modify such constipation. 

This method of modifying milk has been followed for years, by many 
of the medical profession, as a substitute for mother's milk or as an alter- 
nate with Horlick's malted milk. 

This food is also indicated as a diet for dyspeptics, fever patients, and 
convalescents, as it is easily digested, palatable, and free from some of the 
objectionable features that pertain to the use of milk alone, as a diet. 

Cereal Milk. 

Cereal milk is a malted dried-milk food. It is stated by its makers to 
be a complete food, cooked and ready for use with the simple addition of 



186 NUTRITION. 

water, and to be made from the purest Vermont dairy milk, the finest 
wheat gluten flour, the best barley malt, and milk-sugar. 

Cereal milk in general appearance very much resembles the other 
malted dried milk foods, but it contains a much greater percentage of milk- 
sugar, showing that this substance is used in its manufacture, as claimed. 

The directions for preparing it for use are to mix 1 teaspoonful of 
cereal milk in a teacupful of hot water for infants under three months of 
age or for a very delicate child. 

Preparation for a child six months old: — ■ 

"To make 6 ounces Prepared Food, use 3% rounding teaspoonfuls Cereal Milk 
Powder," as directed. 

Composition when prepared : — 

Table No. 31. 

Cereal Milk. Woman's Milk. 

Water 90.98 86.73 

Total solids 9.02 13.26 

Fats 0.38 4.13 

Proteins 1.09 2.00 

Inorganic salts 0.21 0.20 

Carbohydrates 7.34 6.93 

The reaction to litmus was neutral, or faintly acid. The food contains 
starch. No white of egg or cream was added, since neither is definitely pre- 
scribed. This fact may be taken into consideration when comparing the 
analysis with that of the other foods. 

The total of soluble carbohydrates as above is practically the same as 
in woman's milk; the amount of proteins is less than one-half the amount 
in woman's milk, and about one-half is insoluble in water. The amount of 
fat is one-eleventh the amount in woman's milk. The small amount of fat 
indicates that the cereal extractives and milk-sugar make up the bulk of the 
solids of this food, and that a dilution of 1 part of good cows' milk with 11 
parts of water would be the counterpart of the above mixture as to the 
amount of milk therein. 

Wampole's Milk Food. 

Wampole's milk food is a malted dried milk food. Its makers 
state that it is made from malted cereals, beef, and milk, and when mixed 
with warm water it is immediately ready for use; no other preparation 
necessary. 

This dried milk food is very nearly soluble in water, owing to the solu- 
ble carbohydrates being so large a constituent. A little less than one-half 
of the proteins is insoluble in water. A small amount of beef extract has 
been combined with the cereal extractives and dried milk. 



IMPERIAL GRANUM. 187 

To prepare it for an infant 6 months to 1 year of age, the directions 
are to dissolve 4 to G teaspoonfnls of the food in 6 ounces of hot water. Com- 
position when prepared by dissolving 6 teaspoonfuls in 6 ounces of water : — 

Table No. 32. 

Wampole's Milk-food. Woman's Milk. 

Water 88.59 88.51 

Salts . 0.46 0.34 

Proteins 1.58 2.35 

Fat , 0.73 2.41 

Maltose, dextrin, etc 7.65 

Milk-sugar 0.99 6.39 

Reaction alkaline. Reaction alkaline. 

Compared with woman's milk, it is seen that the carbohydrates are 
considerably in excess, and the proteins and fat are deficient, the fat espe- 
cially, it being less than one-third the amount in woman's milk. 

One part of good cows' milk diluted with about 3% parts of water 
would be analogous to the dilution of milk in Wampole's milk food pre- 
pared as above. 

Imperial Granum. 

Imperial granum is a farinaceous food to be used as an adjunct to cows' 
milk. 

Its makers state that it is a solid extract derived from very superior 
growths of wheat, nothing more. It appears to be made as claimed from 
wheaten flour and to be mainly composed of torrefied starch. 

For an infant six months of ape it is to be prepared by cooking 3% 
teaspoonfuls of food in 21 ounces of water and 20 ounces of milk. 

Composition when prepared as above: — 

Table No. 33. 

Imperial Granum. 1 'Woman's Milk. 

Water 91.53 88.51 

Salts 0.34 0.34 

Proteins 2.15 2.35 

Fat 1.54 2.41 

Starch 1.22 

Maltose, dextrin, etc 0.58 

Milk-sugar 2.71 6.39 

Reaction alkaline. Reaction alkaline. 

The total of solids contained is one-quarter less* than in woman's milk; 
the carbohydrates are nearly one-third less than the amount in woman's 
milk, and it should be observed that 1.22 per cent., or about one-fourth of 
them, consist of starch; there is only a slight deficiency in the amount of 

1 According to Chittenden. 



188 NUTRITION. 

proteins, but a considerable deficiency in the amount of fat. By using more 
milk or milk and cream and less water than above employed the percentages 
of fat, proteins, and soluble carbohydrates would be increased. 

Its very large proportion of starch forms the principal objection to this 
food. 

The presence of unconverted starch causes the thick condition of the 
mixture. 

Eskay's Albumenized Food. 1 

This food is to be prepared with cows' milk. Its makers state, in 'rec- 
ommending their product, that it contains the more easily digested cereals, 
combined with egg albumin. 

Eskay's albumenized food consists largely (about 88 per cent.) of car- 
bohydrates; the soluble carbohydrates, mostly milk-sugar, are about 50 per 
cent., and the insoluble carbohydrates, mostly starch, are a little less than 
40 per cent. On account of this proportion of starchy matter in the dry 
food, it may be termed farinaceous. The makers, however, claim that in 
the process of manufacture the starch granules are almost entirely disin- 
tegrated, and when the food is prepared with milk according to directions 
the percentage is said to be not over iy 2 to 2 per cent. An analysis of the 
dry food shows that it contains about 9 per cent, of proteid matter, but 
when prepared according to the six months' formula it analyzes about 2.55 
per cent. 

The fats as well as the proteins are almost entirely vegetable, with a 
small percentage of each derived from eggs. Excepting the egg, fat, and 
albumin, the preparation is produced from wheat, oats, and barley, and, while 
no proteolytic ferments are used in its manufacture, the insoluble carbo- 
hydrates are nevertheless partially converted into dextrin by a special 
process of heating, which ruptures the starch granules and converts a small 
amount of the starch. 

The egg albumin is said to be first combined with sugar of milk in 
such a thorough manner that the particles are finely subdivided, and no 
firm, hard coagulum can therefore take place in the stomach. The particles 
retain their identity, and do not coalesce; so that in the finished prepara- 
tion the egg albumin is suspended throughout the whole mixture in very 
fine particles, which are easily digested, because the gastric juice acts by 
contact, and, the smaller the particles, the greater the effect of the gastric 
juice. No claims are made by the manufacturers for its solubility, but for 
its ease of digestion and its nutritive value. 



1 The chemical analyses of Eskay's food, Mellin's food, cereal milk, and malted 
milk here given were specially made for me by Professor Lafayette B. Mendel, at the 
Sheffield, Laboratory of Physiological Chemistry, Yale University. 



MELLIN'S FOOD. 189 

The directions for preparing it for an infant six months of age are to 
take : — ■ 

Eskay's food 5 tablespoonfuls 

Hot water 1 pint 

Rich cows' milk 2 pints 

As directed. 

Composition when prepared as above : — 

Table No. 34. 

Eskay's Food. Woman's Milk. 

Water 84.4G 8G.73 

Total solids 15.54 13.2G 

Fats 3.07 4.13 

Proteins 2.78 2.00 

Inorganic salts 0.58 0.20 

Carbohydrates 9.11 6.93 

The reaction to litmus was amphoteric. 

The food contains a noticeable quantity of starch, which is in the form 
of a thin paste, in which all the grains are ruptured by the process of prepa- 
ration. The boiling was carried on for fifteen minutes in the sample an- 
alyzed. 

Eich milk (4.85 per cent, of fat) was used as specifically directed. 

Melltn's Food. 

Mellin's food is a malted cereal. This food is stated by its makers to 
be a soluble dry extract from wheat and malt, for the modification of fresh 
cows' milk. 

Analysis. 

Fat " .16 

Proteins 10.35 

Maltose 58.88 

Dextrins 20.69 

Soluble carbohydrates 79.57 

Salts 4.30 

Water 5.62 

' 100.00 
The salts, 4.30 parts, consist of: — 

Bicarbonate potassium 2.536 

Phosphate potassium 897 

Phosphate calcium 037 

Phosphate magnesium 213 

Phosphate iron ' 016 

Chloride sodium 097 

Sulphate sodium 131 

Sulphate potassium 383 

4.310 



190 • NUTRITION. 

The carbohydrates therein are in the form of dextrin and maltose, and 
constitute about 80 per cent, of the food; the proteins amount to about 
10 per cent, and are derived from the cereals. Mellin's food is almost com- 
pletely soluble in water. It is especially noticeable that this food does not 
contain any starch. 

Whole Milk Formula for Normal Infant, Six Months Old or Over. 

Mellin's food 3^ level tablespoonfuls 

Milk 12 ounces 

Water 4 ounces 

Analysis of Above Mixture: 

Fat 2.67 

2.52 



( cereal 



Pr0teinS - .1 .49 3.01 

Carbohydrates (no starch ) 7.12 

Salts .71 

Water 8G.49 

100.00 
Calorics per fluidounce 21 

The reaction to litmus was amphoteric. The food gave no reaction for 
starch. Milk having 4.25 per cent, of fat was used in this preparation. 

In total solids this food differs but slightly from woman's milk, and in 
the various constituents its similitude to woman's milk is remarkably close. 
Of the carbohydrates the maltose and dextrin are a little less in amount 
than the milk sugar, and the total carbohydrates (7.12 per cent.) are greater 
than the amount in woman's milk. 

One level tablespoonful of Mellin's food added to a 16-ounce mixture 
increases the percentage of 

Proteins 0.14 per cent. 

Carbohydrates 1.10 per cent. 

Salts' 0.06 per cent. 

Mammala. 

Mammala is claimed to be a milk from which a part of the cream has 
been removed, an additional proportion of milk sugar added, and then dried 
by the Hatmaker process, at a temperature of 280° F. 

It is a white powder to be dissolved in hot water with no addition of 
sugar or lime water. It is a simple formula and one adapted for substitute 
feeding. 

The absence of a live factor such as an enzyme would contraindicate 
the use of such food for a prolonged period. We must always bear in mind 
the possibility of the development of scurvy where an absence of fresh milk 
exists. 



BENGER'S FOOD. 191 

Just's Food. 

Maltose, free 12. G parts 

Maltose, combined with dextrin as maltodextrin 15.5 parts 

Dextrin, with trace soluble starch G1.3 parts 

Albuminoids 1.1 parts 

Fat 0.1 part 

Ash 0.9 part 

Water 5.3 parts 

Cellulose 0.2 part 

Indeterminable, (insoluble) . 3.0 parts 

100.0 parts 

This sample was neutral in reaction; the sample was analyzed Jivne 
14, 1895; was slightly acid, which suggests that the process of manufac- 
ture has been changed a little. The food has no diastasic action. 

The small amount of albuminoids, light color of the food, and the low 
degree of conversion, particularly of the last sample analyzed, indicate very 
conclusively that no considerable quantity of malt or any entire cereal is 
used in its manufacture. It is not hygroscopic — it can be exposed to air 
for quite a long time without becoming sticky. 

Upon examination, the above analysis indicates a close relation of Just's 
Food to commercial glucose, although it contains no dextrose. 

A product similar to Just's might be obtained from the glucose process 
if the process were stopped early in the conversion before the starch was 
converted to glucose; that is, when the conversion of the starch has pro- 
gressed only as far as dextrin and maltose; or it might be possible, during 
the process of making glucose, to draw off a portion in the earlier stages 
of the process, and neutralize and clarify, and obtain a product similar to 
Just's food. 

In order to get such a percentage, as is given in the analysis of dextrin 
and maltose, from a starch material by the action of malt diastase, it would 
be necessary to use so much malt that the amount of albuminoids contained 
would be much larger than is shown by the analysis, and the product would 
have a decided malt flavor and quite a marked color, and these Just's food 
has not. 

Benger's Food. 

Benger's food contains ferments which convert the proteins and starch 
during the preparation. It consists of cooked wheaten meal, to which is 
added the natural digestive ferment of the pancreas. 

Analysis by Chambers Watson. 

Water 11.2 

Protein 10.4 

Fat 1.1 

' Soluble 0.9 

Carbohydrates \ Starch . . 66.3 

Ash 9.9 



192 NUTRITION. 

The preparation recommended is as follows :— 

Mix 2 tablespoonfuls (about an ounce) of food and 4 tablespoonfuls of 
cold milk, then add 8 ounces of boiling milk and water ; set aside in a warm 
place for fifteen minutes, then bring to the boil. 

When mixed with warm milk as recommended, the carbohydrates are 
nearly all converted into soluble dextrin and sugar, and the proteins are 
also partially peptonized. This form of food is adapted for marasmic and 
atrophic infants where a predigested food is indicated temporarily. 

Peptogenic Milk Powder. 

This product is stated by its makers to be an article containing milk 
sugar and a digestive ferment capable of acting on casein, offered for the 
preparation of an artificial infant food. McGill states : "It is not, in the 
strict sense, a food. Its professed object is so to change the composition 
of cows' milk as to render this comparable to human milk. This it seeks 
to do by introducing milk sugar and small quantities of albuminoids/' Ac- 
cording to McGilPs analysis, it is composed almost entirely of milk sugar 
(96.6 per cent.). 

The following analysis is by Leeds, and is taken from a circular of the 
makers. 

Composition of "humanized milk" prepared as directed, using 4 meas- 
ures of peptogenic milk powder with y 2 pint of milk, y 2 pint of water, 
and 4 tablespoonfuls of cream : — 

Table No. 35. 

Humanized Milk. Woman's Milk. 

Water .. 86.20 88.51 

Ash 0.30 0.34 

Proteins 2.00 2.35 

Fat 4.50 2.41 

Milk-sugar . 7.00 6.39 

Reaction alkaline. Reaction alkaline. 

Chittenden's analysis of this "humanized milk" is almost identical with 
the above. 

The proteins of the cows' milk undergo a change in the peptonizing 
process, being converted chiefly into partial peptones, and in this form they 
cannot be said to resemble the proteins of woman's milk, which have not 
been acted upon by a proteolytic ferment. 

The prolonged use of peptogenic powder may do harm. It should be 
used as a corrective for several weeks and gradually be replaced by a higher 
protein content. Excessive carbohydrate feeding will do harm ; this caution 
applies as well to peptogenic powder. 



PEPTOGENIC MILK POWDER. 



193 



Table No. 36. — Summary Giving Comparison of the Foods Analyzed by 
Professor Mendel. 





Cereal Milk. 


Malted Milk. 


Mellin's Milk. 


Eskay's Milk. 


Human Milk. 


Water 

Total solids 

Fats 


90.98 
9.02 

0.38 
1.09 
0.21 
7.34 

neutral 


90.74 
9.26 

0.63 
1.65 

0.36 
6.62 

alkaline 


85.37 
14.63 

3.16 

3.03 
0.70 

7.74 

amphoteric 


84.86 
15.54 

3.07 
2.78 

0.58 
9.11 

amphoteric 


86.73 
13.26 

4.13 


Proteins 

Inorganic salts.. 
Carbohydrates . 

Reaction to litmus 


2.00 
0.20 
6.93 



(The figures indicate percentages by weight.) 



The figures quoted for human milk are well-known averages; it would 
be more accurate to give figures indicating the healthy variations. 



CHAPTER VII. 
CONCENTRATED PREPARATIONS OF ALBUMIN. 

Among the concentrated preparations of albumin on the market are : — ■ 

Somatose. 

Somatose, meat albumin, isolated artificially by chemical process. A 
remedy which has more the character of a pharmaceutical preparation of 
a stimulant tonic, rather than of a food. This is evident also in its cost. 
It is used extensively and with good results. It is advisable to be cautious 
with the same owing to the diarrhoeal tendency. It should, therefore, not 
be given to very young infants. 

Chemical analysis : — 

Water 11.41 parts 

Digestible albumin 41.21 parts 

Peptone 27.12 parts 

Other nitrogenous substances estimated by difference 
and assumed to consist of meat basis and ex- 
tractives 14.51 parts 

Asli 5.75 parts 

100.00 parts 

Somatose is stated to be prepared from meat. It is a light-yellow pow- 
der, odorless, nearly tasteless, and readily and completely soluble in water. 
The solution has a slightly alkaline reaction. 

The substance is a predigested, nitrogenous food. 

It is probably made from animal substances, but we are unable to 
state from what materials or by what process the article is manufactured. 
Its contents of phosphoric acid and potassium are very much less than 
should be the case if it were prepared from muscular tissue, or meat in the 
usual sense of the term. 

Eucasin. 

Eucasin is an ammoniated salt of casein. A soluble preparation of 
casein, obtained by chemical process. It contains phosphorus, 0.8 and 13.1 
per cent, of nitrogen. It is well tolerated by older children, but does not 
prove very satisfactory in very young infants. 

Nutrol. 
Nutrol is the sodium compound of casein; also soluble. 
(194) 



ALBUMINOUS FOODS. 195 



Tropox. 



Tropon is a mixture of animal and vegetable albumin. Obtained chiefly 
from buckwheat flour by dissolving with dilute caustic soda, precipitating 
with acid, and purifying with hydrogen peroxide. It was introduced by 
Finkler (Berlin, Min. Wochen., 1897, Xos. 30, 33). Also sano-tropon, 
which is really a mixture of dextrinized barley flour with tropon. Sana- 
togen is very similar to the latter preparation, and consists of casein with 
glyeero-phosphate of sodium, and 13 per cent, nitrogen. 

Plasmon. 

Plasmon is a preparation of casein, partly soluble. Obtained by chem- 
ical process, the use of carbonic acid and bicarbonate of soda. It is adapted 
for the strengthening of ordinary broths, but it must be distinctly remem- 
bered that all of these preparations are merely suggestions as "substitutes, 75 
and should never be thought of as suitable for constant feeding. 

Sosox. 

Soson is a new albuminous product resembling plasmon and tropon 
in nutritive qualities. 

Other foods are Sanosc-Albumosc (Schering) ; also Sanalogen, Eu- 
lactol, Protogen (Blum), and the Somatose Cream Mixture of the Elber- 
felcl Farbemrcrke. 

All of the above preparations have been used by the author in doses of 
Y 2 teaspoonful added to either barley soup, chicken broth, farina, or rice 
gruel. 

When typhoid fever and such disorders tax the ability of the attend- 
ing physician, owing to the rejection of food, then, and then only, should 
milk or its dilution be laid aside and the above foods given a trial. Valu- 
able service has been frequently given by such standard preparations as 
panopepton, liquid peptonoids, and Mosquera's beef jelly where the gastric 
irritability prevents the regular administration of milk. 

Mosquera's Beef Meae. 

This is a partially digested beef preparation, containing in addition 
to the proteins 13.06 per cent, of fat. 
The analysis is : — ■ 

Water 6.68 

Salts and inorganic substances 4.20 

Fats 13.06 

Insoluble proteins 47.61 

Albumose 29.43 



196 NUTRITION. 

Taking the insoluble proteins, albumose and fats, together, 100 grams 
are equal to 435 calories, while the albumose alone represents 122 calories. 



MosqueraV Beef Jelly. 

This beef jelly contains 12.66 per cent, of albumose and 14.35 per cent, 
meat extractives. It represents therefore the stimulant as well as the nu- 
trient qualities of beef. 

A two-ounce jar is equal to 34 calories from the albumose, and if we 
were to take the meat extractives at the same ratio the total number of 
calories would be 94. 

Panopepton. 

Panopepton represents the products of the peptic digestion of fresh, 
lean beef, and of the proteolytic and amylolytic digestion of whole wheat; 
proteins in the form of albumose and peptone, carbohydrates as achroo- 
dextrins and maltose, and the natively associated soluble, savory, and 
stimulant mineral constituents. These soluble food constituents are ster- 
ilized, concentrated, and, after being duly proportioned, are redissolved in 
sherry wine. 

Panopepton contains 20 per cent, of solids as follows: — 

Soluble proteins 6 per cent. 

Carbohydrates 13 per cent. 

Ash 1 per cent. 

It will be noted that the ratio of proteids and carbohydrates is as 1 to 
2.16, which is best calculated for a proper nutritive balance. Harrington's 
analysis shows that it yields 17.99 per cent, of solid matter (including 0.97 
per cent, of mineral matter) and 18.95 per cent, by volume of alcohol. 

This is undoubtedly one of the best predigested foods of the class that 
contains both proteins and carbohydrates in their most available forms, and, 
from the data supplied by its manufacturers, it is evident that it is designed 
upon scientific principles to represent the varied constituents of a mixed 
diet, and that its preparation is carried out in a most perfect manner in all 
respects. The wine serves both as a stimulant and preservative, and the 
product has an agreeable taste and flavor. One hundred grams (about o 1 / s 
ounces) equal 77.5 calories. 

It must not be taken for granted that because one chemist finds a very 
high percentage of alcohol in a standard preparation the same amount 
will be found by other chemists; for instance, the preparation of "liquid 
peptonoids," made by the Arlington Chemical Co., was sent to Dr. Ernst J. 
Lederle. This chemist found 17.59 per cent, alcohol by volume. 



ALBUMINOUS FOODS. ly? 

Table No. 37. — Chemical Analyses by Dr. Ernst J. Lederle and 
J. A. Deghuee, Ph.D. 

An interesting comparison as to the alcohol content can be made by studying 
the analyses of the six nutritive tonics submitted for examination; they are: — 

Nutritive Liquid Peptone 23.49 per cent, alcohol by volume 

(Parke, Davis & Co.) 
Liquid Peptonoids 17.59 per cent, alcohol by volume 

(Arlington Chemical Co.) 
Mulford's Pre-Digested Beef . . . . 19.39 per cent, alcohol by volume 

(H. K. Mulford & Co.) 
Tonic Beef 17.04 per cent, alcohol by volume 

(Sharp & Dohme) 
Trophonine 18.98 per cent, alcohol by volume 

(Reed & Carnrick) 
Panopepton 20.05 per cent, alcohol by volume 

(Fairchild Bros. & Foster) 



CHAPTER VIII. 

ADDITIONAL NUTRIENTS AND STIMULANTS. 

Meigs's Food. 

Meigs's food consists of milk, cream, sugar, gelatine, and arrowroot, 
and is prepared as follows : Of Russian gelatine or isinglass, 20 grains, or a 
piece about two inches square, is soaked for a few minutes in cold water, 
and then boiled in half a pint of water for fifteen minutes, or until com- 
pletely dissolved. One teaspoonful of arrowroot is mixed to a paste with 
cold water, and then added to water to make half a pint. This is now added 
to the gelatine solution, as is also, with constant stirring, the desired quan- 
tity of milk; just before removing from the fire the cream is added. The 
amount of milk and cream used should vary with the age of the infant. 
For an infant under one month, 4 ounces of milk and 1% ounces of cream 
are to be used; for those older the milk is gradually increased to 16 ounces 
and the cream to 2 ounces. 1 

Zoolak:. 

The subjoined analysis of Dr. Dadirrian's zoolak was made by Edgar 
E. Wright, of Brooklyn, K Y. 

In every 100 parts of zoolak there are : — 

Water 87.69 

Protein substances 3.98 

Fat 4.91 

Milk sugar 2.03 

Alcohol 0.07 

Ash or mineral salts 0.78 

Lactic acid 0.50 

Carbon dioxide • 0.04 

This analysis shows that in the production of zoolak but little change 
is wrought in the percentage composition of the original cows' milk, save 
what would naturally he produced by the fermenting and peptonizing actions 
of the kefir ferment. 

These fermentative changes — primary and secondary — consist in: — 

1. The transmutation of a portion of the natural milk sugar into 
alcohol, lactic acid, and carbon dioxide. 

2. The transmutation of a certain percentage of the protein sub- 
stances into proteoses, and finally, perhaps, into true diffusible peptones. 



1 Meigs and Pepper: "Diseases of Children," 1887. 

(198) 



LECITHIN. 199 

This latter action, however, does not change the percentage presence of the 
protein bodies, as related to the total quantity of milk, but simply changes 
their chemical form. 

Owing to the instability of the Bulgarian bacillus in dry or tablet form, 
it is advisable to procure a fresh culture in liquid form, which can be used 
as an antifermentative in gastrointestinal colic, and especially in con- 
stipation. 

The Nutritive Value of Eggs. 

It is commonly asserted that an egg contains as much food value as a 
half-pound of meat. This is not true. While there is an approximate 
equivalent between the albuminoids contained in both, the egg contains no 
carbohydrates. Very young infants do not digest eggs, and frequently gas- 
tric disturbances result from their use. This does not necessarily imply 
that the white of egg in its raw state should never be used as an adjunct to 
other forms of feeding, or as a temporary food when milk disagrees or when 
diarrhocal conditions, such as fermentative and catarrhal intestinal dis- 
eases, prohibit the use of milk. 

Lecithin. 

Lecithin is a crystallizable fat of a peculiar nature containing nitrogen 
and phosphorus. It is unstable. When chemically treated by neurin and 
glycerine phosphoric acid can be isolated. Lecithin has also been found in 
the yolk of egg, in the egg of fish, etc. Hoppe-Seyler isolated this sub- 
stance in 1870 from its constant association with phosphorized albumins, 
nucleo-albumin, and nucleo-protein. Lecithin is also found in the brain 
matter. 

Free lecithin has been used clinically and physiologically by Danilewski 
in 1895. According to this physiologist, animals fed with lecithin grew 
more rapidly than those not fed on this substance. It is a reconstructive 
and is indicated in the treatment of all disorders of nutrition. My experi- 
ence with lecithin has been limited to rachitis, tuberculosis, and cases in 
which atrophy due to malnutrition is found, such as result from pertussis. 
I am also using it in cases of sporadic cretinism. 

A preparation of lecithin containing one grain of pure lecithin to the 
drachm is made by Fairchild Bros. & Foster, of New York City. A tea- 
spoonful of this solution given three times a day before meals has given me 
very good results. 

Lecithin of the Egg. — According to Coloumbe, lecithin exists in all 
the tissues, especially in those endowed with great vitality. From a thera- 
peutic point of view it is not toxic, and it is assimilated as a whole in 
ordinary doses. Its action consists in increasing the number of red cor- 



^>00 NUTRITION. 

puscles; in increasing, in certain cases at least, haemoglobin; in increasing 
urea and diminishing nric acid, and in stimulating the appetite. Its em- 
ployment is indicated in anaemia, in all troubles of nutrition, in wasting dis- 
eases, and in neurasthenia. It may be administered hypodermically or by 
the mouth. 

Steak Juice or Meat Juice. 

The juice of broiled steak possesses anti-scorbutic properties. I have 
referred to this in the chapter on scurvy. When dentition is delayed or 
when the bony structure is weak, as in rickets, steak juice should be freely 
given. It is best prepared fresh each day. For this purpose a meat press 




Fig. 54. 

or lemon-squeezer is convenient. From a pound of lean steak, slightly 
broiled, about three ounces of juice can be obtained. This may be slightly 
salted and given cold or warm, but not sufficiently heated to coagulate 
the albumin. 

If the taste is objectionable, it may be given in milk; two to three 
teaspoonfuls added to eight ounces of milk will not be noticed. The 
milk should not be warmed above 100° F. before the addition of the 
steak juice. 

For older children we can add the steak juice to mashed potato, 
spinach, or rice. Bread or toast saturated with steak juice is liked by 
many children. 

When fresh steak juice cannot be obtained, then Valentine's meat 
juice can be tried. For the treatment of scurvy fresh meat juice must 
be used. 

Chocolate and Cocoa. 

The addition of cocoa to milk is a valuable adjuvant. The flavor of 
cocoa will frequently render the milk more palatable. Where fat is needed, 



ICE-CREAM AND WATER-ICES. 201 

especially in the anaemic, rachitic, and marasmic child, cocoa is indicated. 
High fats are demanded, for example, during cough, or during con- 
valescence following influenza, bronchitis, or pulmonary lesions. It is of 
especial value in tuberculosis. While cocoa is looked upon with disfavor in 
the treatment of intestinal disorders, it will be found of advantage in con- 
stipation for two reasons: first, because of the high fat content; second, 
because of the mechanical stimulus which cocoa exerts in exciting peristaltic 
waves. It is also indicated as a restorative following the acute infectious 
diseases and where considerable emaciation exists. 

Cocoa is made from bitter chocolate by expressing part of the cocoa 
butter and grinding the partially defatted material to a fine powder. The 
amount of cocoa butter remaining varies from 20 to 30 per cent. Cocoa for 
drinking purposes has about 25 per cent, cocoa butter. Cocoa of this com- 
position has a calorific value of about 1769 calories per pound, and contains 
approximately 19 per cent, protein. A teaspoonful of cocoa powder, required 
to make a cup of the beverage, would therefore have a fuel value of about 
20 calories. Added to the caloric value of a cup of 4 per cent, milk, 
which is 120 calories, we have the caloric value of a cup of cocoa, which is 
140 calories. 

Analysis of Hersiiey 1 Cocoa Powdee. 

Fat 24.12 per cent. 

Moisture 3.57 per cent. 

Crude fiber 4.4S per cent. 

Total ash 5.17 per cent. 

Water-soluble ash 2.06 per cent. 

Water-insoluble ash 3.11 per cent. 

Alkalinity (soluble of ash) 1.85 c.c. N/10 acid per gramme sample, 

(insoluble) .... 4.51 c.c. N/10 acid per gramme sample. 

Bitter chocolate is the product obtained by grinding cocoa nibs (roasted 
cocoa beans). Such bitter chocolate contains about 52 per cent, of cocoa 
butter. 

Siveet chocolate is the same as bitter chocolate with the addition of 
about 50 per cent, of sugar, depending on the formula. Its caloric value 
is about 2G20 calories per pound. 

Ice-cream and Water-ices. 

Ice-cream and water-ices are very grateful to a feverish child. When 
milk and cream are refused they will be greedily taken. These prepara- 
tions will alleviate the pain on swallowing in the case of diphtheria. They 
contain considerable nourishment, but must be given in moderation. Nau- 
sea and vomiting may frequently be controlled by them. 



1 This cocoa is manufactured by Hershey, of Pennsylvania. 



202 NUTRITION. 



The Use of Coffee in Children. 1 

Contraindications. — When giving coffee to children we must bear in 
mind that : — 

First. — Coffee is in no sense a food, because it can neither build up 
the tissues nor provide them with potential energy. 

Second. — Coffee perhaps acts the part of a lubricant to the machinery 
of the body, and exerts its stimulating influence by toning up and dimin- 
ishing nervous fatigue in adults, and is not called for in children. 

Third, — Coffee produces a disturbance of digestion due to a direct 
interference with the chemical part of the process, but in part also indi- 
rectly brought about by the nervous system; it also produces a dyspepsia 
which is of the atonic type, and a slow digestion, accompanied by flatu- 
lence, with a disturbance of the heart's action, so that it is decidedly con- 
traindicated from a feeding standpoint. 

Coffee is a cardiac stimulant, quickening the heart's action in small 
doses, and depressing it in large quantities. 

It certainly disturbs the cardiac rhythm when taken in excessive doses 
by children. Such symptoms as muscular tremor, nervous anxiety, and 
dread of impending danger, as well as palpitation ; cardiac intermissions, 
and an uncomfortable feeling referred to the cardiac region can be traced 
to coffee, according to Yeo ; it is a diuretic, and increases the excretion of 
urea; it produces insomnia, nervousness, and fear; also, choreiform move- 
ments. 

Caffeine has been known to produce paralysis in the lower animals, 
and might produce a similar effect if taken in large quantities by children. 
It retards digestion ; hence it is contraindicated in children. 

Owing to the great tendency to produce insomnia coffee should not be 
administered in the evening unless the heart's action demands it. 

Indications. — As a cardiac stimulant, or whenever caffeine is indicated, 
hot coffee should be given in small doses, one or several teaspoonfuls, re- 
peated every fifteen minutes, until its physiological effect is manifested. 
This can only be noted by studying the puke. Great care should be exer- 
cised in administering large quantities of coffee to children, or very strong 
coffee, as in either instance it will produce a marked cardiac depression, 
and also a disturbance of the cardiac rhythm. 

In the convalescence of typhoid fever or pneumonia in children, there 
is no better stimulant than coffee administered in small doses to which 
large quantities of milk or cream are added. This is an especially valuable 
drug in the great cardiac depression so frequently noted in the convales- 



x Paper read by me before New York County Medical Association, December 17, 
1900, "Acute and Chronic Coffee Poisoning." See Transactions. 



ALCOHOL. 203 

cence of diphtheria. (See chapter on "Diphtheria.") The coffee usually 
used consists of the following strength : — 

Coffee 2 ounces 

Water , 1 pint 

When an infusion of the above strength is made, Hutchison found 
that each teacupful of coffee contained :— 

Caffeine 1.7 grains; and also 

Tannic acid 3.24 grains 

The latter in the form of gallo-tannic acid; so that judging from this 
analysis, coffee should be made much weaker (one ounce to a pint of water), 
and should be administered in teaspoonful doses. 

For fuller details on "Physiological Effect of Coffee," read paper and 
discussion at the New York County Medical Association, 1900, by Leszyn- 
sky, Fischer, and others. 

The Use of Alcohol in Children. 

Alcohol in the form of wine or beer or whisky, in any and every form, 
is not only detrimental to the infantile organism, but will leave permanent 
injury if its use is prolonged. There is a decided difference between the 
continual use of alcohol as a food and its use when indicated as a medicine. 
Physicians know that whisky or wine, given to stimulate the weakened heart 
in the course of a septic pneumonia or diphtheria, is not only necessary, 
but frequently the only means of prolonging life. If a child has been given 
alcoholic drinks daily as an adjuvant to other articles of food, when it is 
required to stimulate the heart we must resort to enormous doses to procure 
an effect. 

Alcohol should be regarded as a poison ; therefore, as an irritant to the 
kidneys. The growing child does not assimilate alcohol. It interferes with 
the metabolism of fat and protein, and its use therefore should be limited 
to stimulating the heart when weakness exists during a septic process. 

In a large children's clinic with which I have been associated it was 
very interesting to study the amount of alcohol given to young children, 
and I was surprised to find that more than 50 per cent, of all children from 
six months old and upward regularly received their sip of beer or drop of 
whisky "to strengthen their hearts." The author has frequently attended 
alcoholic dyspepsia due to prolonged use of beer and wine. This is most 
common among the tenement population, where the baby forms part of the 
family at the table, and necessarily partakes of almost everything eatable 
and drinkable along with its parents. 

In the routine examination it is the duty of every physician to inquire 
into the habit of giving alcohol to children. 



204 NUTRITION. 



The Use of Tea in" Children. 



In my chapter on the use of coffee, I have already mentioned the 
deleterious effect of coffee on the growing infant or child; what has been 
said there regarding coffee applies equally strong to the use of tea. The 
nervous system when overstimulated in an infant is far more sensitive than 
the adult. The author has frequently noted that children suffered with 
sleeplessness and were very irritable, simply through the prolonged use of 
such stimulants as tea and coffee. A noteworthy point is that the appetite 
disappears when tea and coffee are given, and reappears when their use is 
interdicted. 

It must not be supposed that tea is a poison, and there are times when 
physicians will find it necessary to use small quantities of tea to stimulate 
the body, as, for example, in that form of exhaustion following a protracted 
diarrhoea, as is usually the case in summer complaint, so-called cholera 
infantum. 



PART IV. 

DISEASES OP THE MOUTH, (ESOPHAGUS, STOMACH, 

INTESTINES, AND RECTUM, AND DISEASES 

ASSOCIATED WITH IMPROPER NUTRITION 



CHAPTER I. 
DISEASES OF THE MOUTH. 

Stomatitis. 

Alsr infection existing on the tonsils or in the pharynx can spread to 
the mouth. Food, especially milk, is sometimes the means of directly con- 
veying poison ; this is especially true when milk contains pathogenic bac- 
teria. As I have frequently stated that syphilis and rickets undermine the 
system, so also we find these conditions frequently as predisposing causes. 
The mouth is particularly liable to local infection. The slightest trauma- 
tism by diseased teeth, especially in acute cases, can produce local irritation. 
Non-pathogenic bacteria are always present in the buccal cavity under nor- 
mal conditions. 

"The glands of the mouth being excretory frequently produce inflam- 
matory conditions by virtue of systemic poison excreted by them which 
may produce local lesions." One of the best writers on this subject is 
Forchheimer, whose classification I have adopted : I. Stomatitis Catar- 
rhalis. II. Stomatitis Aphthosa. III. Stomatitis Mycosa. IV. Stomatitis 
Ulcerosa. V. Stomatitis Gangrenosa. VI. Stomatitis Crouposa; Stoma- 
titis Diphtheritica. VII. Stomatitis Syphilitica. 

Stomatitis Catarrhalis. 

Simple stomatitis may be confined to a local area or it may be general. 
When the mucous membrane is irritated by severe rubbing, as during mouth 
cleaning, this condition frequently follows. Dentition does not produce 
stomatitis. This catarrhal form is usually one of the earliest manifesta- 
tions of acute infectious diseases. Great stress is laid on this condition 
as a diagnostic point in measles prior to or associated with the enanthem 
on the buccal mucous membrane. When a small area is affected, a local 
cause, such as a diseased or sharp tooth, or some mechanical cause, must be 
looked for. 

(205) 



206 DISEASES OF THE MOUTH. 

Symptoms. — The usual symptoms of pain, hyperemia, and swelling 
are noted. The lining of the mouth is puffed and hypersemic. The mucous 
membrane is covered with small, round prominences due to the swelling of 
the muciparous follicles. When the ducts of the latter become closed the 
glands dilate and there are produced cysts, the contents of which are clear, 
viscid mucus. We also find slight epithelial abrasions, sometimes leading 
to the production of a deeper process ; at all events important in that they 
may become the seat of infection. The lymphatics are usually involved, 
and they serve as a guide to the intensity of the inflammation. Cases are 
on record where the temperature reached 104° F. in the rectum, but these 
are rarities. 

The prognosis is invariably good. Unless some chronic disease is the 
seat of this trouble there are rarely any disagreeable after-effects. 

Treatment. — The treatment consists in cleanliness. Eemove the cause 
if possible. Eemove mechanical irritants, such as diseased or sharp-pointed 
teeth. Boric acid, 1 per cent, solution, or sulphocarbolate of zinc or sulpho- 
carbolate of soda, 1 grain to the ounce, are valuable local astringents. At 
times nitrate of silver (2 grains to the ounce) will act well when applied 
locally. Forchheimer recommends the application of silver nitrate when 
there is loss of epithelium. Cysts should be opened and their walls cau- 
terized when necessary. My best results are obtained by the use of argyrol, 
5 to 10 per cent, solution. 

Stomatitis Aphthosa. 

This condition is not follicular and has nothing to do with the mucip- 
arous follicles, as it is found in places where there are none. 

It consists in a hyperemia of the mucous membrane of the mouth 
associated with superficial ulcers. 

Causes. — There seems to be a decided reason for believing that this 
disease is of microbic origin. Aphthous ulcerations have been seen in 
children partaking of milk from cows that suffered with foot and mouth 
disease. Demme 1 reports a case of twins fed on goat's milk, the goat having 
foot and mouth disease. The milk was fed fresh and raw. One of the 
twins, the boy, had a severe aphthous condition of the entire mouth and 
throat, and died after seven days of illness. The other, a girl, was also 
sick with aphthous sore mouth, but recovered after five days' illness. 

Eobinson 2 reports a severe epidemic of aphtha? acquired from foot 
and mouth disease in Devonshire. Two hundred and five persons were 
affected in one week. Two children died, the aphthous condition having 
extended to the respiratory tract. 



1 Vienna Medical Journal, vol. vi, 1883. 

2 London Practitioner for 1884. 



STOMATITIS APHTHOSA. 



207 



Boas, of Berlin, has also reported cases of foot and month disease and 
their results. Bohn states that the disease is most common between the 
tenth and thirteenth months of life. Therefore, teething has something to 
do with the eruption. Siegel studied an epidemic of foot and mouth dis- 
ease, resulting in aphthous stomatitis in children. An ovoid bacillus 0.5 ^ 
long was found in all cases. We can assume that foot and mouth disease 
in cattle is the etiological factor of stomatitis aphthosa in the human being. 
Symptoms. — White or yellowish-white epithelial spots are seen singly 
or in groups, surrounded by an areola and developing anywhere in the 

mouth. In many cases 
they extend into the 
pharynx, and Forch- 
heimer believes into 
the larynx. This dis- 
ease is frequently as- 
sociated with acute 
gastric catarrh, consti- 
pation, and with gen- 
eral toxaemic condi- 
tions. The eruption 
may be preceded by 
pain in the throat, 
fever, enlargement of 
the lymphatics, and a 
general train of nerv- 
ous symptoms so com- 
mon in children. 

The diagnosis, 
therefore, will be diffi- 
cult until the erup- 
tion appears. The 
spots frequently are 
absorbed. Successive crops may come and go. 

Treatment. — The treatment consists in giving laxatives such as rhu- 
barb and magnesia, or inf. senna comp. The diet must be regulated. If 
the child has been given solids they should be excluded. The discontin- 
uance of milk is frequently beneficial. 

Locally, a weak solution of listerine as an antiseptic can be used. If 
the child is old enough it should rinse its mouth and gargle its throat with 
the same. Nitrate of silver, 10 grains to the ounce, or in some instances 
tincture of chloride of iron, has served me very well. The glycerite of car- 
bolic acid applied with absorbent cotton is frequently efficacious. 




Fig. 55.— A Case of Sprue (Thrash) due to Faulty 
Hygiene of the Mouth. Note Threads (Mycelium) and 
Small Oval Bodies (Spores). (After Jagic, Klinische Mi- 
kroskopie.) 



208 DISEASES OF THE MOUTH. 

Bednar's Aphthae. 

The small, yellowish-white, ulcerative patches which appear on one or 
both sides of the hard palate in the new-born are known as Bednar's aphthse. 
They may be mistaken for the ulcers produced by the breaking down of 
milia or retention cysts, or for that condition described by Epstein in 
which there are congenital defects in the mucous membrane filled up with 
epithelial detritus (Forchheimer). They are usually the result of violence 
in cleaning the mouth. Frequently an improperly shaped nipple will cause 
this condition by pressing on the palate. 

Dr. A. Jacobi, in the Archives of Pediatrics, says : — 

"Do not be so fearfully clean. Perhaps it is best to leave the infant's 
mouth alone with the exception of the first washing with sterilized water 
immediately after birth. Otherwise the mouth should be cleaned by the 
baby's feeding and by the practice I have recommended these dozen of years 
— viz. : to give a teaspoonful or two of water after every feeding. That will 
wash down all remnants of food that might get decomposed in the mouth. 
These 'aphthae' will get well when left alone; but as long as there is a 
sore surface there is a possibility of microbic invasion; for that reason 
alone they should be treated." 

The affected area should be gently wiped with cotton wound around 
the finger, and dipped into a saturated solution of boric acid. 

Stomatitis Mycosa, or Parasitic Stomatitis. 

This disease is commonly krrown as thrush, sprue, soor, or muguet. 
It occurs in the mouth in the form of yellowish-white spots and is due to 
a microbe. A fungus was first discovered by Berg, of Stockholm, and called 
oidium albicans by Eobbin. Forchheimer states that the fungus is found 
in two forms, the yeast form and the globulofilimentous form (frequently 
called mycelium). "There is no ascospore, therefore. Koux and Linoissier 
state that the fungus is not a saccharomyces. The chlamydospore has, 
however, not been satisfactorily worked out." 

Propagation goes on in three ways : by filaments produced from conidia, 
by isolated conidia, and by spores. 

Symptoms. — Local symptoms vary with the severity of this condition. 
At times no symptoms precede the appearance of these small spots. The 
spots are grayish white or creamy in color. They may be elevated above 
the surface of the mucous membrane. They are not confined to the gums, 
but appear frequently on the lips, tonsils, pharynx, and cheeks. There is 
a fetid breath due to the inflamed gums. Children that are old enough to 
complain do not describe any subjective symptoms. The lymphatic glands 
are always enlarged and do not suppurate. When suppuration takes place 
it will follow after the disease in the mouth has disappeared. 



CROUPOUS STOMATITIS. 209 

Treatment. — Prophylactic treatment of the month., consisting in the 
usual hygienic measures, can prevent this condition. Aseptic details must 
be rigidly enforced in the nursing bottles and nipples when this disease is 
present. 

Treatment consists in the application of a 1 per cent, boric acid solu- 
tion as a mouth cleanser, followed by the local application of a 3 per cent, 
chlorate of potassium solution. Where a specific cause exists, such as 
carious teeth or dead bone, the same should be removed before attempting 
to cure this condition. 

Croupous Stomatitis, or Diphtheritic Stomatitis. 

This rare condition is occasionally met with in children. The prog- 
nosis and treatment should be considered just the same as though we were 
dealing with diphtheria in the throat. The following interesting case was 
sent to my clinic at the Xew York Post-Graduate Medical School in 
1891-:— 

The child was seven months old, female, breast-fed, had always been in good 
health. Xo family history of tuberculosis, lues, rheumatism, or epilepsy. The child 
was vaccinated when about six months old, had had no previous illness excepting 
slight irritability about the time of the eruption of the first tooth. It has two 
teeth, incisors, lower jaw. General appearance not anaemic or rachitic, has well- 
nourished muscles and a fair amount of fat. Skin has a healthy appearance. Four 
other children in same family, three apparently healthy; the fourth is convalescing 
from an attack of "sore mouth." The infant has been gaining weight regularly since 
birth. It now weighs 15 pounds and S ounces. 

An examination of the infant showed: Two large patches — one on the tip of 
the tongue; the other on the soft palate — which were irregular in outline, yellowish- 
green in appearance. Temperature in the rectum IOOI5 F., at 11 a.m. ; pulse, 142; 
respiration, 39. Cervical glands considerably enlarged on both sides. Xo history 
of existing infectious disease in the same locality. The diagnosis of stomatitis 
ulcerosa was made and a question mark (?) entered after the same. Diphtheria. 
was suspected. The mother was cautioned in regard to the other children, and the 
case carefully watched. I again saw the case two days later and found the child 
in a worse condition. The temperature in the rectum at 4 p.m. was 102%° F. ; 
pulse, 160; small, feeble, but quite regular. The examination of the mouth showed 
an extension of the inflammatory condition of the patches, now involving the uvula 
and left tonsil. The pharynx showed an abnormal redness, but no membrane was 
visible.' 

The mother's breast was painful on palpation. The glands were distended 
with milk, and the axillary glands enlarged and tender on palpation. The mother 
complained of aching in her limbs — a "tired feeling."' as she called it — and had 
chills, alternating with fever. Her temperature was 99%° F. in the mouth. 
There were membranous patches around one of her nipples. This resembled a 
cracked nipple. While examining the infant's mouth I saw what appeared to be 
membrane. A similar condition was found around the nipple. I inoculated two 
agar-agar tubes and placed them in the thermostat. After twelve hours, small 
colonies of both streptococci and bacilli could be seen. On staining with LoelBer's 

14 



210 DISEASES OF THE MOUTH. 

alkaline methylene blue, showed distinct semblance to Klebs-Loeffler bacilli. A 
culture was made from the patch in the mouth, from the uvula, and also from the 
pharynx. The tube inoculated with the uvula patch and the one from the tongue 
contained, in almost pure culture, the characteristic Klebs-Loeffler bacilli. The usual 
method of treatment and active stimulation was given. Concentrated liquid diet 
(rectal feeding) was given when the infant refused the breast. An important 
question suggested itself: Shall we wean the infant? or, mother and infant having 
the same disease, could the infant be nursed on the healthy breast? It will be 
remembered that only one nipple was diseased. I resolved to give the infant the 
milk of the healthy breast and to guard against another sore nipple by nursing 
through a glass nipple shield. The milk in the diseased, or left, breast was drawn 
out with a breast-pump and thrown away. 

Three weeks after the apparent cure of the mother's breast and also after the 
last visible membrane from the infant's throat disappeared, the mother complained 
that she slept with one eye open. On examination, I found a distinct facial paralysis 
on the right side. The diagnosis was strengthened by the sequel in the case. To 
sum up: I believe the infant, while having diphtheria, infected its mother through 
the fissure of the breast during the act of nursing. Considering the physiology of 
nursing, we know the role played by the tongue, and, as the disease was first mani- 
fested thereon, it can be readily seen how this might have been inoculated from 
tongue to the breast through its cracked nipple. 

Syphilitic Stomatitis. 

Primary infection in syphilis is by no means rare. It usually occurs 
by transmission from a wet-nurse suffering with syphilis. 

A case of this' kind was seen by me in an infant nine months old. This 
infant was accidentally infected by a woman who nursed it during the mother's 
illness. She had erosions (cracked nipples) and did not know that she suffered with 
syphilis. Her own child died of distinct syphilis, having had pemphigus and the 
general cachexia so common in luetic conditions. This case was given small doses 
of calomel, and given a bichloride bath (see chapter on "Syphilis") and showed signs 
of improvement almost immediately. In the mouth of this child the ordinary mucous 
patches were found. 

Treatment is that of syphilis. (See chapter on "Syphilis.") 

Noma (Stomatitis Gangrenosa; Cancrum Oris 1 ). 

This disease is frequently called noma, and sometimes cancrum oris. 
It is characterized by a gangrenous destructive process located on the 
cheek. Although the left cheek is the favorite site of the disease, ( it can 
frequently be found on both cheeks. The writer has met with children 
suffering from this disease on the right cheek. Girls are more liable to 
noma than boys. It is usually secondary to some contagious disease, and 
has been known to follow typhoid fever, smallpox, scarlet fever, measles, 
pertussis, and allied infectious disorders. We must, therefore, assume 
that the infectious diseases are predisposing factors in the development of 
this disease. ' 



1 Extracted from the American Journal of the Medical Sciences, April, 1902. 



NOMA. 211 

The process usually commences on the gums or the inner portion of 
the cheek, and spreads very rapidly to the adjacent tissues. Thus it is 
that it will destroy the inner portion of the cheek and spread to the outside, 
causing similar destruction to the healthy tissues. 

Bacteriology. — Perthes 1 in 1899 found that noma -is due to a fungus-like 
growth belonging to the streptothrix group. At the border line between the 
gangrenous ulcer and normal tissue he found a thick, branching network of 
fine, fusiform threads — mycelium. From this mycelium single, fine rods and 
spirilla extend into the normal tissue, surround the cells, and cause their 
death. Krahn believes that the growth. described by Perthes consists of two 
organisms — the spirillum sputigenum and spirochete dentium. The major- 
ity of observers agree with Perthes and Seiffert. The same bacteriological 
picture was described in noma of other parts of the body by Matzenauer. 
Perthes prepared his specimens for examination by treating the teased tissue 
or section from the edge of the ulcer — removed post mortem — with dilute 
carbol-fuchsin for twenty-four hours and then briefly washing with alcohol. 
Weaver and Tunnicliff 2 demonstrated that this streptothrix is decolorized by 
Gram's method. They obtained the best staining reactions by dropping a 10 
per cent, saturated solution of alcoholic gentian violet in 5 per cent, phenol 
on the section (that had been embedded in paraffin, treated with xylol, fol- 
lowed by absolute alcohol) for five minutes, clearing with aniline oil, wash- 
ing with xylol, and mounting in balsam. A complete bibliography of noma 
is given by Weaver and Tunnicliff. 3 

Symptoms. — The cheek will appear swollen, hard, and cedematous to 
the touch, the oedema causing such swelling that frequently the eye of the 
affected side cannot be opened. There is a decided fetor to the breath, 
which is often the first symptom noticed. The disease spreads very rapidly 
from the gums to the cheek. Frequently the teeth will loosen and fall 
out. The latter is frequently caused by the previous administration of 
mercury. Thus it is that great care should be used in giving mercury to 
children. 

That it is not an inflammatory disease can be seen by the fact that 
the temperature is rarely or never above normal. The swelling can best 
be felt by opening the mouth and grasping the cheek between the thumb 
and forefinger. The skin over the induration is frequently mottled with 
purple spots resembling ecchymoses. The appetite is diminished, partly 
due to the fear of pain caused by chewing. 

Some authorities state that children so affected have diarrhoea. Forcli- 
heimer believes that haemorrhages rarely occur, owing to the blood-vessels 
being filled with thrombi. 



x Arch. fur klin. Chir., 1899, lix. 

3 Journal of Infectious Diseases, 1907. 

3 Journal of Infectious Diseases, Jan., 1907. 



212 



DISEASES OF THE MOUTH. 



When this gangrenous mass discharges we will find a dirty, fetid 
saliva, with threads of broken-down tissue. The cervical glands in the 
immediate vicinity are always found enlarged. In severe cases it is not 
rare to have the parts ulcerate and even perforate the cheek after several 
days. When the disease extends inward, not only does periostitis occur, but 
necrosis of the jaw-bone has been noted. When the disease is as malignant 
as has just been described, then subnormal temperature, possibly delirium, 
may complicate the condition. The disease may extend to the lungs, caus- 




Fig. 56. — Case of Stomatitis Gangrenosa (Noma) Following Scarlet 
Fever. The picture shows the unilateral gangrenous condition involving 
the right cheek and the lips. Case recovered. Clinical history given in 
the text. (Original.) 



ing a gangrenous infiltration. When the gangrene affects the genitals in 
girls, then a serious prognosis must be given. 

The following cases will illustrate the condition described : — 

Elsie G., aged 7 years, was seen by me in January, 1900. The child had com- 
plained of severe headache for three or four days, and was very feverish. Her 
mother became alarmed because of persistent vomiting. She stated that the child 
vomited at least six times in twenty-four hours. She complained of feeling fatigued 
and had pains in her arms and legs. 

The child was nursed for ten months, and was a. strong baby up to this time; 
dentition commenced at the seventh month; the child's muscles and bones were 
well developed; there were no evidences of rickets; the first two years were passed 



NOMA. 213 

without any sickness except an occasional attack of constipation. The child walked 
at the end of the first year and commenced talking at its fourteenth month. Twenty 
teeth — "milk teeth" — appeared at the end of two years. The child had measles in its 
third year, which left a bronchitis; the mother states that this same cough recurs 
every winter. The child had had whooping-cough, lasting four months, which was 
so violent that it had epistaxis almost every day for one month. This whooping- 
cough was so severe that, in addition to the nose-bleed, the child vomited almost 
continuously. From loss of sleep, in addition to the above-named symptoms, the 
child commenced to emaciate. This was at the end of her fifth year. 

When the child was undressed an eruption was found all over the body, which 
was that of typical scarlet fever. The throat was filled with evidences of pseudo- 
membranous patches, which were distinctly scarlatinal in character. The tempera- 
ture was 103.4° F., taken in the rectum; pulse, 128; respiration, 22. The child 
was put to bed and an expectant plan of treatment ordered, in addition to a very 
light liquid diet consisting of soup, milk, buttermilk, broth. Nothing else was 
allowed; no solids were given. For the thirst I ordered orange juice and apple 
sauce. Small doses (wine-glasses) of citrate of magnesia were given for their laxa- 
tive and diuretic effects. 

The heart sounds were very feeble, and a loud, blowing, hsemic murmur, which 
was attributed to the anaemic condition, w 7 as audible. Iron was given in the form 
of the syrup of iodide of iron; hypophosphites were also administered as restoratives. 
Convalescence lasted in all until April, a period of almost three months from the 
time of the child's first illness. About this time she complained of pain in the gums 
and on the cheek while chewing. Later, the foul breath attracted attention. At first 
this condition was attributed to the teeth, but a dentist who saw the child found the 
teeth and gums healthy. The ulceration, which had now become quite marked, from 
the size of a silver dollar, spread with remarkable rapidity. Its color w y as that of a 
dirty, blackish gray, and had purpuric spots scattered around the edges of this 
ulceration, resembling subcutaneous haemorrhages. On examining it considerable 
fluid, which was very foul smelling, exuded on pressure. Antiseptic lotion, consisting 
of 50 per cent, peroxide of hydrogen diluted with water, was ordered as a mouth 
wash. The child was told to rinse the mouth every half-hour, especially after eating. 
The gangrene extended to the outside of the cheek, involving, as can be seen by the 
illustration, almost the whole cheek. 

The streptothrix is usually present in the pregangrenous stage and it is 
here in this stage that the best therapeutic results are attained. As a rule, 
the disease appears in epidemic form. In diphtheria, scarlet fever, and espe- 
cially measles oral hygiene must be instituted to prevent stomatitis, and 
especially ulcerative stomatitis. The latter is frequently a soil for the de- 
velopment of noma and hence every case of stomatitis should receive active 
treatment to prevent gangrene. 

The following case was seen by me at the Willard Parker Hospital dur- 
ing my service in April, 1913 : — 

Child C, 3 years old, was admitted with a moderately severe type of scarlet 
fever. Later a complication of noma developed, and this was the reason for the 
injection of 0.2 neosalvarsan. Within three days after the injection a slight im- 
provement was noted, which continued steadily until the case recovered, in all ten 
days from day of first injection. The noma involved the pharynx, tonsils, and soft 
palate. 



214 DISEASES OF THE MOUTH. 

When fetor of the breath exists, a strong solution of permanganate of 
potassium as a gargle or spray every two hours will deodorize. Internally 
tincture of iron as a restorative. The insufflation of a small quantity of 
neosalvarsan used locally once a day is advised. If fever exists, and toxaemia 
complicates, an intravenous injection of 0.2 neosalvarsan dissolved in 40 
c.c. of sterile water and injected into the jugular vein has shown marked 
improvement in a number of my cases. 

Epithelial Desquamation (Geographical Tongue). 

A very common condition consists of epithelial desquamation of the 
tongue, giving rise to irregular, round or crescent-shaped patches. The 
borders of these patches are surrounded by a thickish, grayish margin. The 
center has a glazed appearance. From the irregular outline resembling a 
map the name of geographical tongue originates. 

There are usually two or more of these red patches seen at one time. 
They last weeks and months. I have met these cases among the poorest 
hygienic surroundings and have seen the same condition among the wealthy. 
Malnutrition seems to be associated in all my cases. I have frequently seen 
cases of this kind among the children suffering with diphtheria at the 
Willard Parker Hospital, especially during convalescence. The following 
case illustrates this condition: — 

Minnie H. Fourteen months old. Has been in delicate health since birth. 
Although breast-fed, has always been constipated and suffered with gastritis, and 
vomiting occasionally. 

She is very ansemic. Can neither stand, walk, nor talk. Dentition has been 
delayed; there is no sign of teeth. Tlie tongue shows four large, irregular shaped 
patches and two smaller ones in the center. They appear as though a coated 
tongue had irregular patches of red, and shining flesh interspersed. Diagnosis, 
rickets and geographical tongue.. 



Treatment. — Increase the proteins and fats to stimulate nutrition, 
nse the tc 
no treatment. 



Cleanse the tongue with boric or tannic acid solution. Most authors advise 



Congenital Hypertrophy oe the Tongue. 

A thickened, swollen tongue is always seen in sporadic cretinism. (See 
chapter on "Cretinism.") The specific thyroid treatment will usually 
modify this enlargement. When diseased lymphatics exist we may have 
a lymphangioma. Such conditions are rare, and if present require surgical 
treatment. 

Bifid Tongue, 

Brothers reported a case of this kind to the New York Pathological 
Society. The child was one month old, had a cleft tongue and a fissure of 
the soft palate. 



PLATE VII 




Geographical Tongue, or Epithelial Desquamation. 
(Original.) 



ALVEOLAR ABSCESS. 215 

Bifid Uvula. 

This condition is occasionally seen. I have seen bifid uvula several 
times without cleft palate. Some authors report the co-existence of bifid 
uvula with cleft palate. It requires no treatment. 

Glossitis. 

An inflammation of the tongue is very rare in children. Some authors 
state that it is due to traumatism, such as biting the tongue in an epileptic 
fit, or a ragged, sharp tooth may infect the tongue and cause inflammation. 
Any irritation, such as caustic acids or alkalies, may cause inflammation. 

The following case occurred in my private practice : — 

A child 1 year old was bottle-fed, and suffered with severe constipation. He 
was backward in development, had no teeth, could neither walk nor talk. Several 
adults in the family had influenza and the child was exposed and infected. The 
fever reached 104° F. There was anorexia, cough, and running of the nose. The 
tongue was thickened and inflamed and protruded from the mouth. He refused to 
take any food and seemed relieved when a piece of ice was placed on the tongue. 
Ice cream was ordered to nourish and cool at the same time. Rectal suppositories 
containing aconite, 1 minim, and sodium salicylate, 3 grains, were ordered every two 
hours. Under this treatment, aided by ice applied on the tongue and an ice collar 
on the neck, the swelling of the tongue disappeared in about four days. 

Eanula. 

A swelling in the floor of the mouth, located on either side of the 
frsenum, is frequently met with in children. It is a cyst varying in size, 
and is due to an occlusion of the duct leading into the mouth from the 
sublingual gland. 

Character. — It may be simple or multilocular. It may be of such pro- 
portions as to interfere with proper nutrition. 

Symptoms. — The symptoms are those of a mechanical obstruction of 
a non-inflammatory character. It is painless, soft, fluctuating, and con- 
tains mucus. The color of the growth is the same as that of the adjacent 
parts. 

Treatment. — An incision should be made to evacuate the contents of 
the sac. The interior of the sac should be cauterized with iodine or nitrate 
of silver. In some instances the Paquelin cautery may be required. 

Alveolar Abscess. 

When there is defective hygiene in the mouth and the teeth are not 
properly cleaned, caries of the teeth results. The carious condition fre- 
quently sets up an inflammation, and pyogenic bacteria, gaining entrance, 
cause abscess formation at the root of the tooth. 



216 DISEASES OF THE MOUTH. 

Symptoms. — The symptoms are pain, swelling, fever, interference with 
feeding, foul breath, and general constitutional disturbances. The diag- 
nosis can be made by the presence of fluctuation in the mouth, by the 
swollen face, mouth, and jaw. 

Treatment. — Locally, warm (dry) chamomile bag or warm (moist) 
flaxseed poultices will have a soothing effect, used externally over the swell- 
ing. Rinsing the mouth with warm chamomile tea to which a few drops 
of listerine have been added is grateful. Painting the gums with equal parts 
of tincture of iodine and tincture of opium every hour will relieve pain. 
If fluctuation is detected an incision should be made into the gums on the 
inner surface, and the pus evacuated. If this condition is neglected the 
periosteum of the jaw may be involved and the pus will burrow and evacuate 
itself spontaneously, leaving a disagreeable fistula. Cases have been reported 
where neglect of this condition has resulted in necrosis of the jaw. 

Angina Ludovici. 

Angina Ludovici is an inflammation of the cellular tissue of the floor 
of the mouth and neck. It is probably a form of actinomycosis. The 
swelling is most marked below the jaw of one side. The symptoms are 
very intense and both local and general. There are general septic symptoms 
from the outset. With the swelling there are oedema and board-like indura- 
tion. Redness and the rapid formation of an abscess occur rarely. The 
throat is not affected. Death takes place from reflex suffocation or in 
coma. 



CHAPTEE II. 
DISEASES OF THE (ESOPHAGUS. 

Acute Oesophagitis. 

An" inflammation may extend from the pharynx into the oesophagus. 
When such conditions arise the symptoms of pain on swallowing are asso- 
ciated with fever. The treatment consists in giving bland food, milk, 
seltzer, and alkaline waters or water containing bicarbonate of soda. 

Croupous or Diphtheritic Oesophagitis. 

Diphtheria can invade the oesophagus as well as it can spread to the 
larynx. Some authors describe croupous inflammatory patches in the 
oesophagus. I have seen diphtheria of the oesophagus and also a diph- 
theritic patch post-mortem in the stomach of this same case. Such a con- 
dition is invariably serious and recovery is rare. The treatment of diph- 
tlieria affecting the oesophagus is the same as that described in the chapter 
on "Diphtheria." When dysphagia occurs and there is an interference with 
deglutition, rectal feeding may be demanded to save life. 

If severe pain exists morphine or codeine in suitable doses. Nau- 
sea and vomiting can best be controlled by giving large doses of chloral. If 
an oesophageal stricture remains, then surgical treatment will be required, 
for which the reader is referred to modern text-books on surgery. 

EETRO-ffiSOPHAGEAL ABSCESS. 

This condition may follow measles, scarlet fever, or diphtheria ; in fact, 
it may be associated with any infectious disease. As a rule, this disease con- 
sists of a breaking down of the lymph glands ending in suppuration. In 
a case seen by me the streptococcus was found. This condition is also 
frequently associated with tubercular conditions. The following case will 
illustrate the type most frequently met with : — 

I was called in consultation with Dr. S. Brothers to see a child 3 years old 
with the following history: — 

There was fever, an irritant cough, stertorous breathing, and evidence of 
obstruction pointing to the larynx. The neck was swollen and the glands enlarged. 
The temperature was 102° F.; pulse, 130; respiration, 36. At first the case resem- 
bled one of laryngeal stenosis as is usually found in diphtheria. The dyspnoea was 
so marked that intubation was suggested. The symptoms pf dyspnoea continued, 

(217) 



218 DISEASES OF THE (ESOPHAGUS. 

and an incision was made into the posterior pharyngeal wall. The abscess cavity 
extended into the oesophagus. Caries of the dorsal vertebrae was associated with 
this condition. The child died from inanition. The tubercular process was evidently 
responsible for the abscess, which consisted of pus and large curded masses. The 
diagnosis . was made after a careful study of the case. It is not an easy matter to 
diagnose this condition, as it is absolutely impossible, in some cases, to reach the 
abscess cavity by a digital examination of the pharynx. 

In the case above reported the dyspnoea was very alarming. The litera- 
ture records cases of spontaneous evacuation of the abscess into the oesoph- 
agus resulting in recovery, but usually these cases end fatally. The treat- 
ment is surgical, and tuberculosis, if present, requires the usual form of 
treatment. (See chapter on "Tuberculosis.") 



Fig. 57. — Hinged Bucket. 



Foreign Bodies in the (Esophagus. 



I have frequently been consulted regarding the removal of buttons, 
coins, etc., which were swallowed. The habit of children to put everything 
into the mouth should be remembered when buying toys. 

The best method of extracting foreign bodies in the oesophagus is by 
means of the hinged bucket; also known as the "coin catcher." 



CHAPTER III. 
DISEASES OF THE STOMACH. 

Acute G-astiuc Catarrh (Dtspepsia; Gastritis). 

One of the most frequent diseases met with in infants or young chil- 
dren is dyspepsia. This is due to improper feeding of both quality and 
quantity of the food. Nursing children are very often seen suffering with 
this disease, especially among the tenement population. That poor hygiene 
has some bearing on the development of this disease is certain. 

The largest number of cases are seen with bottle-fed babies. Errors in 
feeding, particularly over-feeding, and giving the infant the bottle whenever 
it cries, must be looked upon as a means of aggravating and exciting 
gastritis, if not being the real cause of the dyspepsia. 

Pathology. — The mucous membrane of the stomach is always swollen 
and thickened. Occasionally erosions and haemorrhages are found. The 
tissue beneath the mucous membrane, the submucosa, will be found cedema- 
tous. The interstitial tissue is infiltrated with leucocytes, and the differen- 
tiation between the parietal and principal cells cannot be clearly outlined. 
All the cells appear cloudy and granular and partially separated from the 
membrana propria of the gland. There is an abundance of the mucous 
cells in the pyloric region, and this increase extends deeply into the ducts 
of the glands. 

In older .children the origin of the trouble can easily be traced. Over- 
eating, especially cakes and pies and puddings; too rapid chewing and 
swallowing of unmasticated pieces will aggravate an attack of this kind. 

Gastritis is seen more often in older children who are permitted to 
drink wine or beer at the table with their parents. Children are permitted 
a drop of whisky or wine or beer, as their parents say, "to strengthen them." 
Candies and ice creams frequently cause acute gastritis in children. 

Symptoms. — A young infant will suddenly refuse to take its bottle and 
will appear very peevish and thirsty, flex its legs on its abdomen, will seem 
dissatisfied, and refuse to play. Vomiting is a frequent symptom. The 
infant will cry and put its fingers into its mouth. The temperature on the 
first day ranges between 102° and 103° F., though it may reach as high as 
105° F. in the rectum. The pulse ranges between 140 and 160. The res- 
piration is sometimes accelerated. The tongue is usually coated with a 
white or a grayish-white fur, and there is a foetid odor to the breath. Diar- 
rhoea may be present, although constipation is more frequently met with. 

When children are extremely anaemic, or if from previous malnutrition 
they are rachitic, the disease will commence with convulsions. Convulsions 

(219) 



220 DISEASES OF THE STOMACH. 

must not be looked upon as very serious unless they recur several times 
during the first day of the attack. 

A diagnosis of meningitis will frequently be made in the commence- 
ment of an acute catarrhal gastritis, unless we study the pulse-rate. In 
meningitis the pulse-rate is usually slow ; in gastritis it is greatly accelerated. 
Pressure on the epigastrium will show marked tenderness. The stomach 
is usually distended and tympanitic on percussion. 

If a child is old enough to complain, there are usually subjective symp- 
toms such as headache, frontal in character, and pains in the arms and 
legs will be described. Jaundice will usually be found in older children in 
the course of the disease, and denotes an extension of the catarrhal inflam- 
mation from the stomach into the duodenum; thus gastro-duodenitis may 
be diagnosed when jaundice is established. 

Prognosis and Course. — The prognosis of an acute catarrhal gastritis 
depends on the time of the year and the condition of the child at the time 
of the attack. If a bottle-fed infant is attacked with gastritis in midsum- 
mer, and it cannot be removed from the sultry city, then the prognosis is 
grave. If, however, breast-milk can be given judiciously and the feeding 
interval conform with the requirements of the weak digestive apparatus, 
then we may reasonably hope for a favorable termination. If complications 
occur, chief among which may be typhoid fever, or an extension of the 
disease from the stomach into the bowel, then the outlook will not be good, 
unless we can remove the patient to the mountains or seashore. 

Nephritis frequently complicates gastritis, and when such complica- 
tions exist the prognosis is bad. Infectious diseases complicating gastritis 
will render the prognosis unfavorable. 

The important point to note is, how much food is being assimilated. 
If the infant digests a proper quantity of food the prognosis is good; if, 
however, vomiting continues and we cannot feed the child per mouth or 
per rectum, then the prognosis is very grave. We must aim to prevent 
starvation if the child's life is to be saved. 

Treatment. — The first thing to do is to cleanse the stomach. This can 
be accomplished by giving a dose of castor-oil, syrup of rhubarb, or calomel. 
If the child is old enough some citrate of magnesia in wineglassful doses, 
repeated every two or three hours, will correct fermentation. When rapid 
cleansing of the stomach is demanded, owing to toxic symptoms from 
ptomaine poisoning or from other poisons, an emetic should be given. A 
dose of 1 grain of sulphate of copper in a teaspoonful of water, repeated 
every half-hour until vomiting is produced, will materially aid in cleansing 
the stomach. Syrup of ipecac, in teaspoonful doses, may also be given in 
some instances, although the writer does not advocate the use of syrups in 
acute fermentative diseases of the stomach or bowels. In other cases wash- 
ing* the stomach with a soft catheter, as mentioned in the treatment 



ACUTE GASTRIC CATARRH. 221 

of summer complaint, will prove very valuable. Several pints of table salt 
solution or of normal salt solution 1 can be used to thoroughly cleanse the 
stomach until the water is syphoned off quite clear. In washing the stomach 
with the aid of a soft-rubber catheter there is usually quite some irritation 
produced in the pharynx and oesophagus, and thus vomiting will usually 
aid in the lavage in clearing the stomach of its contents. When such treat- 
ment has been instituted it is advisable to allow the stomach to rest at least 
six or seven hours, and meanwhile give sterile water — "ordinary boiled 
water" — ad libitum. 

When the bowels have been properly cleansed and the stomach has 
been washed by lavage, or treated with one of the above-mentioned laxa- 
tives, then the after-treatment will consist in preventing further fermen- 
tation, and also in toning up the patient's condition. 

Medicinal Treatment. — Experiments have shown that when the gastric 
contents have been syphoned off or examined immediately after an emetic 
has been given, in an acute gastritis, there is a deficiency of hydro- 
chloric acid. This is an indication then as to what is required. 

Diluted hydrochloric acid given in doses of from 2 to 5 drops has 
served the writer very well when given every three or four hours. 

I}. Acid hydrochloric dilut 1 drachm 

Essence pepsin (Fairchild) 2 ounces 

M. D. S. Teaspoonful repeated every two or three hours. 

Beta-naphthol bismuth in doses of 1 to 5 grains, every two hours, has 
served me very well. Calcined magnesia 2 is also very valuable. The fol- 
lowing prescription has been used with very good results in dyspeptic con- 
ditions attended with constipation : — 

R- Magnesia usta . : : 1 drachm 

Pulv. rhei 1 drachm 

Saccharum 2 grains 

M. and divide into 12 powders. One powder to be given in a teaspoonful of 
sterile w T ater every two or three hours. 

Powdered charcoal added to the above prescription in doses of 1 grain 
three times a day is frequently useful. Salol in doses of 1 grain every two 
or three hours, and resorcin in doses of V 10 grain or ^ grain, for a child 
1 year old, repeated three times a day, will do good in some instances. 

A very good liquid preparation sold in drug stores is milk of magnesia 
(Phillip's). It is an excellent antacid and- corrective when flatulence 
exists. 



1 Formulae for saline solutions will he found in the chapter. on "Scarlet Fever." 

2 Magnesia in powdered form I frequently use is known as Husband's Magnesia 



in drug stores. 



222 DISEASES OF THE STOMACH. 

When severe thirst exists boiled water may be given. This water may 
he acidulated with a few drops of diluted phosphoric acid, and will be 
found not only very grateful and cooling, but very serviceable if the child 
has a tendency to diarrhoea in midsummer. 

Dietetic Treatment. — The most important point to remember is the 
feeding. If we are dealing with the nursling, then breast-milk should be 
withheld for about one-half day. When the breast is given again, the infant 
should not be permitted to nurse more than two or three minutes, and 
immediately after taking the breast the infant should receive 3 or 4 ounces 
of sweetened rice water. In this manner we will give the infant diluted 
milk. This breast and rice-water feeding should be repeated in four hours, 
no sooner, no matter what the age of the infant. 

What might appear very radical is simply advised, to prevent the stom- 
ach from performing its usual amount of work until the gastric function 
is reestablished. If, however, the child's appetite warrants it, then one or 
two days should elapse before giving it its former regular quantity of nurs- 
ing. The guide to the return of the normal quantity of nursing will be the 
disappearance of the fever and of the accelerated pulse-rate. The child's 
craving for the breast can be noted chiefly by constant crying when the 
breast is removed, and the ravenous manner in which it nurses. 

In bottle-fed babies it is advisable to give the . child one-half of the 
former quantity of milk or cream which it received at the time of its illness, 
and if it is found that the sugar contained in the food aggravates this con- 
dition, a small quantity of saccharine may be used to sweeten the milk, and 
the sugar discontinued. Some children show distinct fermentative changes 
after the use of too much sugar. In such cases the use of saccharine or one- 
half teaspoonful of glycerine to each bottle of milk is sometimes beneficial 
as a temporary substitute. 

Glycerine is absolutely harmless and may be given for months with 
impunity. My rule is to insist on the use of sugar if at all possible. Lime 
water in doses of a teaspoonful or a tablespoonful may be added to the 
milk. Five grains of bicarbonate of soda may be added to the milk or 
given before each feeding. If vomiting follows the milk-feeding, whey 
should be substituted. 

Attention must be paid to the quality of milk given to infants. There 
are many dairies in New York City which furnish an excellent quality of 
milk, owing to the great care bestowed upon the milk supply by the Health 
Department, and also by the Milk Commission. 

If milk seems to aggravate an attack of dyspepsia, then zoolak or 
kumyss or other fermented milk may be tried. Buttermilk is very nour- 
ishing and very useful in dyspepsia. Junket may also be tried; so also can 
whey be given several times a day. Soups and broths, calf's foot and chicken 
jellies are all nourishing. Steak juice and unfermented grape juice will 



ACUTE GASTRIC CATARRH. 223 

be serviceable. Boiled fruits, such as apples aud peaches, if the child is old 
enough and the condition warrants it, may be tried. 

Our aim must be to have the infant fed with a large interval of rest, 
so that nausea and vomiting may be prevented, and in order that the food 
may be properly- assimilated. We must therefore give small quantities with 
large feeding intervals. When the functions are again normal then we can 
return to a judicious, nutritious diet, as demanded by the infantile stomach. 
It is advisable to give nux vomica in doses of 1 minim for a child, 1 to 3 
years old, three times a day before feeding, and to continue the same for 
months after the gastritis disappears. The writer has seen the most marked 
improvement following the use of this drug, and regards it as a specific for 
toning the stomach. 

Malt extract should be given in doses of a half teaspoonful, three times 
a day, to aid nutrition. It is well known that malt has a decided laxative 
effect. Care should be taken that fermentation is not reestablished while 
giving malt. In some cases it is not well borne in the commencement of an 
acute gastritis, aud a total abstinence of milk and the substitution of boiled 
water, whey, soups, and broths may become necessary; very weak tea, to 
which the white of a raw egg has been added and sweetened with saccharine 
or with granulated sugar, can be given with advantage. 

Fever. — The temperature in the course of an acute gastritis requires 
no antipyretic treatment, although sponging the surface or a cold pack, 
applied over the thorax and abdomen, will be serviceable. Specific fever 
treatment is uncalled for. The well-known depressing effect of antipyretic 
drugs must not be forgotten, aud hence the specific cause of the disease 
must be removed. This is usually stagnant food. The same requires clean- 
ing out with calomel or cascara. The cause of the fever will be removed 
with such effectual treatment. 

When children have a tendency to convulsions then a mustard foot- 
bath can be given and an ice-bag applied over the anterior fontanel, or 
at the nape of the neck. In such instances the most rapid treatment will 
be called for, such as washing the stomach with a catheter, using warm salt 
water. An emetic will prove useful in those cases where lavage cannot be 
successfully carried out. 

Alcoholic stimulation is contraindicated in every form of gastric fever. 
The writer has always seen bad results follow the use of whisky when the 
gastric mucous membrane was inflamed. If, however, the patient is threat- 
ened with collapse, or the pulse is very weak, then small doses of musk in 
the form of a tincture of musk can be injected hypodermically, every hour, 
until the pulse-rate improves. Camphorated oil, injected hypodermically, in 
doses of from 5 to 15 minims, may do good in some cases. 

Hot coffee may be given in small doses, two or three teaspoonfuls 
repeated every fifteen minutes, until its physiological effect is manifested. 



224 DISEASES OF THE STOMACH. 



Pyloric Obstruction Caused by Spasm of the Pylorus. 

The symptoms of obstruction of the pylorus, due to spasm or obstruc- 
tion due to hypertrophy, are strikingly similar. It is difficult to differen- 
tiate the fame in many cases. In the one, the spasm is a benign condition 
which yields to and is frequently overcome by mild and palliative remedies. 
In stenosis, however, we have a serious condition and one that has cost many 
lives, despite proper surgical measures. 

Causes. — The most frequent cause of pyloric spasm in infancy is due 
to irritating food, that is, food containing excessive high fat and high 
proteids. Another cause of pyloric irritation resulting in spasm is seen 
when human milk is suddenly withdrawn and cows' milk substituted. When 
there is deficient peptic secretion, including hyperacidity, such condition as 
spasm may be caused by stagnation of the gastric contents. 

Common Symptoms. — The most noteworthy symptom in this condition 
is vomiting or regurgitation. Said vomiting will follow soon after food 
reaches the stomach. In some cases all of the food partaken will be 
ejected; in other cases small quantities will be vomited at intervals. On 
placing the infant in the dorsal position antiperistaltic waves can be noted 
by inspecting the abdomen. These w r aves are seen after food is taken. 
These worm-like movements disappear -when the stomach is empty. From 
the loss of food and improper nutrition there naturally results loss of 
weight. When the spasm yields, the food will pass into the duodenum, and 
resulting therefrom there will be more or less faeces evident. If, therefore, 
stool is noted, then spasm of the pylorus and not stenosis exists. 

Pyloric Stenosis. — When an obstruction due to a pyloric hypertrophy 
and stenosis exists, there results usually a dilatation of the stomach from 
the stagnation of the gastric contents. The evacuations following colonic 
flushing will bring away some jelly-like or greenish masses, but milk 
faeces will not be found. This is an important diagnostic point and will 
differentiate the spasmodic from the stenosed condition. 

In suspected or congenital pyloric stenosis Nobecourt 1 and Merklin 
have shown that normal children, 3 months old, will, by giving 0.015 
giamme of carmine, in three to nine hours pass a red stool. Therefore, the 
retention of carmine must prove an anatomical obstruction somewhere in 
the digestive tract. 

Diagnostic Aid. — A small metallic bucket, devised by Einhorn, some- 
what smaller than an ordinary sized pea, is fastened to a white silk cord. 

This bucket is introduced into the stomach by placing it on the tongue 
and feeding the infant a bottle of water or food. The infant swallows the 



Nobecourt und Merklin, Bull. d. la Soc. d. Pediatrie. 12. I. 1910. 



PYLORIC OBSTRUCTION. 



225 



bucket and the same is allowed to remain in the stomach over night. When 
pyloric stenosis is present the bucket remains in the stomach. If, however, 
there is no stenosis the bucket will pass into the duodenum, and the bile- 
stained string will show the probable depth that the bucket entered the 
duodenum. 

I choose the evening feeding time or about 6 p.m. as the best time for 
introducing the bucket, then give the infant the regular feeding, and with 
very few exceptions the same was retained. If, however, the bucket was 
expelled by vomiting it was reintroduced at the next feeding. To be sure 
that no obstruction to the duodenum existed, I left the bucket in over 




Fig. 5S— Infantile Duodenal Bucket with Syringe attached, to Aspirate Bile. 

night. On withdrawing the same after about twelve hours, a yellowish 
bile-stain from the duodenal bucket for at least 8 to 10 centimeters will be 
noted on the cord. In pyloric obstruction, however, no bile-stain was noted. 

By this method of diagnosis we can learn whether or no pyloric 
stenosis is present. It is an important aid if surgical relief is demanded. 

Instead of a cord, a thin rubber tubing attached to and ending in a 
perforated bucket can be passed into the stomach, and by leaving it there 
several hours the bucket will pass through into the duodenum. By means 
of a little glass syringe, I was enabled to aspirate bile, in some cases a 
greenish, in other cases a yellowish fluid, alkaline in reaction and of 
viscid consistency. 

There are three ferments for which a test can be made. They are: (a) 
steapsin, (b) trypsin, (c) amylopsin. 

(a) To test for trypsin, I use 1 drop of neutral milk, 2 drops of water, 
2 or 3 drops of duodenal contents (neutralized if the reaction is acid), and 
a small piece of blue litmus agar. This is placed into a miniature test 
tube and kept at blood temperature. If steapsin is present the agar will be 
red in twenty, to thirty minutes, owing to the development of fatty acids. 



226 DISEASES OF THE STOMACH. 

( b ) For the demonstration of trypsin I use a small piece of the white 
of a hard-boiled egg, which is placed in the flmd to be examined (if acid, it 
is first neutralized) and kept a few hours at blood temperature. The piece 
of egg albumin disappears in the presence of trypsin. The ricin test used 
for pepsin is unsuitable for trypsin. If we add ricin solution to duodenal 
contents and leave it at blood temperature for a few hours, and then add 
hydrochloric acid or acetic acid, the ricin will often be precipitated, i.e., it 
will not be changed into soluble peptone. 

(c) Amylopsin. In testing for the presence of diastase we make use 
of a boiled starch solution or starch paper. We mix the duodenal contents 
with the starch solution (in equal parts), or insert a strip of starch test 
paper and leave it at blood temperature for one-half to one hour, adding a 
weak solution of iodine. Starch, if present, gives a blue color, and erythro- 
dextrin a red color ; otherwise only a trace of brown from the iodine. 

Hypertrophic Pyloric Stenosis. 

This condition is not so rare in infancy as is commonly supposed. 
While, in 1902 Cautley and Dent reported 109 cases, we have since then 
over 150 cases recorded in medical literature. 

Etiology. — Stenosis may occur as a congenital malformation. Hyper- 
acidity is believed to be responsible for some cases of spasm of the pylorus 
resulting in hypertrophy. Thomson believes that by the ingestion of liquor 
amnii in intra-uterine life both the stomach and pylorus are excited to over- 
action, due to the presence of this irritant fluid. 

Morbid Anatomy.— Under normal conditions the circular muscle fibers 
of the pylorus at birth are relatively augmented, gradually approaching the 
normal as the long axis of the stomach assumes its horizontal direction from 
the vertical; this relative augmentation of the circular fibers is intended 
to prevent the too rapid emptying of the vertical tubular infantile stomach 
during the first two weeks of life. These fibers, stimulated to excessive 
function by any given cause, must, according to recognized physiological 
principles, become hypertrophied. 

Accepting such a working basis, we should recognize in hypertrophic 
pyloric stenosis the ultimate results of a pathological process whose first 
stage is represented by an excessive functional activity of the pyloric muscu- 
lature ; it? second stage by hypertrophy and spasm of this musculature, and 
the third stage by a general overgrowth of the normal constituents of the 
involved parts. 

Symptoms. — There is a sudden onset of symptoms. The food will 
suddenly disagree. There are active peristaltic and antiperistaltic waves 
visible. This is most marked after the infant has swallowed food or water. 
In a case reported by me very strong peristaltic waves could be noticed 



HYPERTROPHIC PYLORIC STENOSIS. 227 

from left to right. 1 There was a distinct hourglass contraction, the stomach 
bulging on either side with a sulcus in the middle. The abdominal walls 
are lax. The intestinal wall, chiefly the transverse colon, can be easily 
mapped out. 

On palpating the pylorus in my own case, a hard, resisting mass about 
the size of an adult's thumb could be felt. Gradual emaciation from inani- 
tion will be noted. 

Stagnation of the gastric contents is proven by the fact that, while 
two ounces of the food are swallowed, six or eight ounces are frequently 
regurgitated and vomited. The quantity of urine is also scant, owing to the 
small quantity of liquid and food absorbed. A whole day will frequently 
pass without a single diaper being wet. 

The examination of the gastric contents shows great variability. In 
my own case, the presence of lactic acid and the total absence of hydro- 
chloric acid were noted. Other observers have noted an excess of hydro- 
chloric acid. 

Prognosis. — If the vomiting persists, death will occur from exhaustion. 
In a case seen by me, where operation was refused, the infant died of inani- 
tion after three weeks. 

Treatment. — Dilute the food to half-strength. If a milk mixture con- 
taining 2 per cent, of fat has been given, then 1 per cent, should be tried. 

There should be a longer interval between the feedings. If a baby 
has been fed every two hours, it should be fed once in three hours. If two 
ounces had been given at one feeding, then one ounce should be tried. If, 
after this method, vomiting persists, then the stomach should be allowed to 
rest at least twenty-four hours, during which time rectal feeding can be 
tried. Stomach-washing every morning with normal saline solution may do 
good in some cases. 

On the theory that hyperacidity caused pyloric spasm, Knoepfelmacher 
used whole milk feedings to modify the hyperacidity. Bromide of sodium, 
codeine, menthol, or subnitrate of bismuth may be tried. 

Surgical Treatment. — If, after a patient trial of the above-outlined 
plan, the condition does not improve, then surgical relief is indicated. In 
this stenotic stage, gastro-duodenostomy in two sittings, if necessary, should 
be the operation of choice. 

"At the first of these, slight fixation of the involved parts to the abdomi- 
nal incision, opening of the duodenum, and the insertion of a temporary 
catheter for purposes of direct feeding. 

"After a proper interval, depending upon the patient's gain in nutrition 
and strength, an anastomosis between this opening in the duodenum and 
the stomach, either by the small button of Meyer or a modification of the 
Finney operation." (Sturmdorf.) 



1 Archives of Pediatrics, May, 1906. 



228 DISEASES OF THE STOMACH. 

Post-operative Treatment. — Strychnine, 1 / 150 grain hypodermically 
every three hours, is required. Normal saline injections, either by high 
colonic flushing, or, if the pulse is weak, by means of hypodermoclysis. 

By mouth, several teaspoonfuls of whey every hour. This method is 
ample for the first few days, after which special feeding rules may be in- 
dicated. 

Gastro-duodenitis (Catarrhal Jaundice). 

When the infection of an acute catarrhal gastritis extends into the duo- 
denum, jaundice usually results. This is due to an involvement of the 
common bile ducts. 

Symptoms and Diagnosis. — Yellowish pigmentation of the skin and con- 
junctival mucous membrane are noted. The urine is brown or deep yellow. 
The stool is whitish or clay-colored. The temperature ranges between 
100° and 103° F. Anorexia and thirst usually exist. Nausea or vomiting 
may occur. The pulse is full and regular. The liver is usually enlarged. 

Treatment. — Elaterine or podophyllin, 1 / 20 to y i0 grain, repeated, if 
necessary, in three hours, or phosphate of soda, 10- to 20- grain doses every 
three hours until liquid stools are produced. Dilute nitro-muriatic acid, 
2 to 5 drops, may be given twice a day. Liquid food, such as thin soups, 
diluted milk or skim-milk or buttermilk, and fruit juices, for thirst. 

Chronic Gastritis (Chronic Glandular Gastritis — Chronic 

Vomiting) . 

This is a chronic inflammatory disease affecting the gastric mucous 
membrane. The functions of the stomach are disturbed owing to the large 
quantities of alkaline mucus being secreted. There is a distinct loss of 
tone in the gastric mucosa. Large quantities of food will frequently stag- 
nate, causing fermentation and vomiting. 

Pathology. — The changes in chronic gastritis, seen post-mortem, are 
similar to those met with in the acute form. There is a degeneration of the 
epithelium of the gastric tubules. Frequently there is dilatation of the 
stomach. 

Microscopically the glands often seem enlarged, sacculated, and dilated 
in cyst-like forms. Ewald states that there is a mucoid degeneration. 
When there is a total destruction of the glandular layer of the entire organ, 
we have an atrophic condition which Ewald calls anadenia ventriculi. 

Symptoms. — Vomiting is a prominent symptom. Large quantities of 
sour or bile-stained mucus are ejected. At other times sour-smelling liquid 
containing particles of food is ejected. Farinaceous foods cause particular 
distress. Pains referred to the abdomen are complained of, and the abdo- 
men is usually distended and tender on palpation. The tongue is coated. 



CHROXIC GASTRITIS. 229 

The papillae are enlarged and the edges and tip are of a bright glazed red. 
Eructations of gas are frequently noted, especially after feeding. 

The Bowels. — Constipation alternates with diarrhoea in this condition. 
We find a child will suffer with constipation for three or four days, and for 
no apparent reason a diarrhoea will appear and continue for a week or 
more. Eczema is usually associated with this condition. There is usually- 
anorexia. Owing to the malnutrition, such children appear underfed and 
seem to be anaemic. They emaciate from loss of sleep in addition to the 
continued vomiting. Their extremities are usually cold, owing to a poor 
circulation. Headache is a prominent symptom in children old enough to 
complain. The clinical picture is such that one must take extreme care 
to make a proper diagnosis. Frequently there is a hacking cough present. 
"We may exclude tuberculosis if the pulmonary signs are wanting in addi- 
tion to the absence of the tubercle bacillus. 

Diagnosis. — The diagnosis is easily made if we remember that tuber- 
culosis has fever which at times assumes a hectic form. We have previously 
mentioned the necessity of finding the tubercle bacillus if tuberculosis is 
suspected. Typhoid fever is so different that we can easily exclude this by 
resorting to the Widal and diazo reactions. Syphilis, if suspected, will 
respond to specific treatment. 

Prognosis and Course. — This condition should be looked upon as every 
other chronic disease in which vitality, surroundings, and proper care play 
an important part. If a child of a poor family living in a tenement house 
suffers with this chronic disease, the outcome will be different than if the 
child were living in the country, where fresh air could and would stimulate 
metabolism. Rarely is this condition fatal, although with extreme emacia- 
tion and continued vomiting inanition may cause death. 

Treatment. — Dietetic Treatment: This is the most important factor. 
The feeding interval should be extended so that the child should be fed 
less often than formerly. The quantity of food should be reduced so that 
the stomach receives less work. By all means give food that is easily as- 
similated. In some cases nothing but predigested food or peptonized milk 
will be retained. Each child should receive a carefully prepared diet list, 
and we must insist on strict rules. Give older children soups, broths, albu- 
min, such as white of egg, and peptonized yolk of egg. Give infants diluted 
milk or one of the infant foods temporarily. When vomiting persists and 
apparently little or no food is retained, it is advisable to put the child to 
bed and resort to rectal feeding for two or tnree days. This is one of 
the best means of allaying gastric irritability. (See chapter on "Bectal 
Feeding.") 

Hygiene. — Without fresh air, active exercise, such as walking, or 
passive movements, such as massage or gymnastics, we must expect little 
or no benefit. Daily sponging or bathing, followed by friction with a coarse 
towel, will stimulate the circulation. 



230 



DISEASES OF THE STOMACH. 



Medication. — Stomach washing, by using 1 or 2 pints of warm water 
to which bicarbonate of soda has been added, is very useful. This may be 
repeated every day. Sodium phosphate, in 5- to 10- grain doses, every morn- 
ing or evening, is indicated. 

Fowler's solution, in 1- to 5- drop doses, three times a day, and nux 
vomica, in 1-minim doses, three times a day. 1 

Bismuth subnitrate or bismuth beta-naphthol, to relieve the diarrhoea, 
are very valuable remedies. 

For persistent vomiting menthol, in 1-grain doses, and oxalate of 
cerium, in 2- or 3- grain doses, every few hours, are useful. Gentle currents 
of faradic electricity will also aid and strengthen the atonic condition. 

Acute Dilatation of the Stomach. 

This condition is quite frequently met with in children. 
Etiology. — The anatomical and physiological peculiarities of the in- 
fantile stomach render it peculiarly susceptible to the development of this 




DILATED STOMACH. 
At age of one month. 



Fig. 59.. — Drawing from a Case of Acute Dilatation of the Stomach, 
Giving Exact Size Post-mortem. Bottle-fed Infant. Summer Complaint, 
Due to Over-feeding, and Too Frequent Feeding. Compare normal" size with 
the dilated condition. (Original.) 



1 Fraser, of New York City, makes a 1-minim nux vomica tablet, which is 
soluble and quite palatable. 



BULIMIA. 231 

condition. The walls of the stomach are thin. The weakness of the re- 
sistance of the muscular walls and the ease with which a general anaemia 
and resultant muscular atony occur in children must be remembered in 
considering etiological factors. Eachitis plays an important part in the 
development of this condition. Severe gastric catarrh with associated 
fermentative conditions are predisposing factors. 

Pathology. — A general atrophied condition of the entire gastric wall 
exists. The muscular coats are frequently thickened. The mucous mem- 
brane shows evidences of chronic catarrh. This condition is usually seen 
in marasmic or rachitic children. The stomach is invariably dilated. 

The symptoms of this condition correspond to those of chronic gastric 
catarrh. In standing the child upright the contour of the greater curvature 
of the stomach can be made out if emaciation exists. Vomiting is a promi- 
nent symptom, a sour, frothy liquid being thrown up. Succussion is fre- 
quently heard, but cannot be depended on as a positive symptom in this 
condition. Children suffering with acute dilatation usually have a very 
good appetite. They always show evidences of malnutrition. The results 
of percussion are very misleading. A tympanitic sound may be heard when 
the child is on its back. It may also be absent. Henoch states that severe 
dilatation of the stomach in a child may cause dyspnoea. It may also dis- 
place the heart if dilatation is severe. 

Diagnosis. — The diagnosis can usually be made by the symptoms above 
described. It is important to remember that a dilatation of the colon may 
exist at the same time; if so the differentiation between dilatation of the 
colon and dilatation of the stomach can be made by artificially distending 
the stomach with the aid of a Seidlitz powder. Transamination of the 
stomach with the aid of a' gastrodiaphane will aid in mapping out the 
anatomical outlines of the stomach. 

Prognosis. — This depends on the condition of the child when treat- 
ment is commenced. If the child is physically debilitated and does ,not 
assimilate food, the prognosis is grave. It is safest to give a cautious 
prognosis in every case. 

Treatment. — Semi-solid foods should be given, if possible, and large 
quantities of liquids avoided. The normal tone of the stomach can best be 
restored by the administration of nux vomica and iron in suitable doses. 
The value of electricity and massage must be remembered. They will 
restore the tone of the stomach when judiciously used. Specific conditions 
such as rickets and syphilis, if present, require their proper treatment. 



Bulimia (Abxorvtal Appetite). 

Constant desire to eat is frequently seen when intestinal parasites, such 
as tapeworm, are present. It is also found as a symptom of hysteria. 



232 



DISEASES OF THE STOMACH. 



A. B., 7 years old, desired five and six meals a day. Her body was emaciated 
and occasional abdominal pains were described. The mother attributed the pains to 
overeating. After several doses of filix mas a tapeworm was dislodged (see treat- 
ment in the chapter on "Tapeworm") and the bulimia disappeared. 



GrASTROPTOSIS (DESCENSUS VeNTRICULI) 

the Stomach. 



Low Position of 



We are indebted to G-lenard 1 for emphasizing sufficiently the clinical 
symptoms due to this condition. 

Etiology. — In subnormal conditions such as chlorosis or where a gen- 
eral atony exists, a weakening of the ligaments takes place and the abdom- 




Fig. 60. — Translumination of the Stomach with the Aid of a Gastro- 
diaphane, in a Case of Gastroptosis. (Original.) 

inal viscera consequently descends. Very tight lacing is frequently a cause 
in young girls. 

In a series of autopsies made by Glenard he found the transverse colon 
displaced and stenosed. 2 

Symptoms. — A variety of nervous symptoms such as irritability, head- 
ache, restlessness by day and insomnia by night, is frequently due to this 
disorder. The symptoms which characterize nervous dyspepsia in the adult 
correspond with the train of symptoms noted in this condition. Constipa- 
tion is usually present; there are loss of appetite and eructations. 



x Lyon medicale, 1885, p. 450. 

2 Einhorn : "Diseases of the Stomach, 



First Edition, p. 368. 



GASTROPTOSIS. 



233 



Diagnosis. — Ewald advises inflation of the stomach as the best means 
of diagnosis. "When the stomach is inflated the lesser curvature, in cases 
of gastroptosis, is visible midway between the ensiform process and the 
navel, or just in the neighborhood of the umbilicus." With the aid of the 
gastrocliaphane we can transluminate the stomach and make out the contour 
of the same. This has been found a valuable means of diagnosis. The red 
illuminated area can be plainly made out if the room is darkened. The 
following case illustrates this condition as met with in practice : — 

Rosie B. was first seen by me when 13 years old. 

Family History. — Father and mother living and well. She has six sisters and 
one brother living, all in good health. There is no family history of syphilis, rheuma- 
tism, or tuberculosis. One child of 3 years died from pneumonia complicating measles. 

Personal History. — She was a breast-fed child and appeared to be well de- 
veloped. She has had measles and with it bronchitis. Menstruation appeared when 
she was 13 years old and lasted seven days. She has complained for the last two 

b 




Fig. 61. — (a) Normal Position of Stomach. (&) Position of Stomach in a 
Case of Gastroptosis. (Original.) 

years of headaches, pains in the back and abdomen, loss of appetite, and does not 
sleep well. She is very nervous and has had a peculiar unilateral twitching in- 
volving the right arm and shoulder. This twitching appears spasmodically and is 
exaggerated when her attention is directed to it. She complains of cold extremi- 
ties, and has an occasional cough. No expectoration. The cough appears to be 
of the same character as that seen in adults which is described as a hysterical cough. 
The chemical examination 1 of the gastric contents syphoned off one hour after 
feeding a test meal of tea and zwieback gave the following: 25 cubic centimeters 
obtained, color greenish yellow, very tenacious, ptyalin present in saliva. Reaction 
of gastric juice acid, no free hydrochloric present, lactic acid absent, peptones 
present, sugar present, starch present, combined hydrochloric acid present, estimated 
by titration equals 0.02 per cent, hydrochloric acid. A splashing sound could be made 
out on the left side of the abdomen in the area bounded by the umbilicus or above 
it to the symphysis pubis. With the aid of the gastrodiaphane the outline of the 
stomach could be plainly seen extending below the umbilicus. In the accompany- 
ing illustration (Fig. 61) the position of the stomach is outlined. 

X I am indebted to Mr. La Wall, chemist, for this analysis. 



234 DISEASES OF THE STOMACH. 

Prognosis and Course. — A displaced organ is not easily replaced by 
giving drugs or by mechanical treatment. The physician should inform 
the patient's relatives regarding the true condition. The life of the child 
is not necessarily endangered by the displaced stomach, yet the abnormality 
should be treated on the principle of general building up of the entire sys- 
tem with special reference to the diet. 

Treatment. — The treatment of these cases consists in building up the 
system with the aid of electricity, massage, and general restorative treat- 
ment; cold sponging with brisk friction of the surface of the body to 
stimulate the circulation; also, light bodily gymnastics. Nux vomica or 
its alkaloid, strychnine, should be given for a long time. 

A tight-fitting abdominal bandage has frequently relieved acute symp- 
toms. Boas, of Berlin; Einhorn, Kemp, and Eose, of New York, are 
among those who advocate supporting the abdominal muscles by this 
mechanical device. 

Surgical Treatment. — When no relief is obtained by the abdominal 
supporter or bandage previously referred to, then surgery may be demanded. 
Some surgeons advise supporting the stomach by means of stitching the 
omentum to the abdominal peritoneum. By this means we have "a method 
of suspending the stomach in a hammock made by the great omentum." 

Ulcer of the Stomach. 

Gastric ulcer is frequently seen in chlorotic girls. It is usually the 
result of living in unsanitary surroundings, or when the body is reduced 
to a subnormal condition. Young girls at or about the period of menstrua- 
tion that are sent to work in factories or shops, who cannot take proper 
time for their meals, are occasionally seen with evidences of gastric ulcer. 
In most cases the ulcer is simply a continuation of a chronic catarrh of the 
gastric mucous membrane which has laid the foundation for this condition. 

Symptoms. — Pain in the stomach, which is distinctly localized and can 
be pointed to in the same area. The pain increases after taking solid food, 
although pain is also noted when any liquid enters the stomach. At times 
bright-red blood will be expectorated, although the blood may be very dark 
in color. There is also a tender area, usually localized between the ninth 
and tenth dorsal vertebras, which is marked on palpation. 

Diagnosis. — The positive diagnosis should only be made after a chem- 
ical examination of the gastric contents is made. The test meal and the 
method of examination are described in Part XII, Chapter II, to which the 
reader is referred. If an excess of HC1 is found in addition to the sub- 
jective symptoms of pain, the diagnosis of gastric ulcer is positive. 

The following case of gastric ulcer was presented by me before the 
New York County Medical Association, May 15, 1899 : — 



CYCLIC VOMITING. 235 

Mary B., 13 years old, complained of headaches and general weakness. She 
was emaciated and had anorexia. She had suffered with constipation, dizziness, 
nausea, and vomiting. Her heart's action was irregular. For four years she 
complained of pain in the middle of the stomach which was always localized in 
the same area. The gastric pains were strongest after partaking of solid food. 
.She had pain whenever any food, solid or liquid, was swallowed. The pain is 
described as a burning pain. She has a tender area between the ninth and tenth 
dorsal vertebrae. This tenderness is marked on palpation. Three years ago she 
had an attack of haematemesis, but none since then. The gastric contents were 
examined after a test meal, and an excess of HC1 was found. Owing to the 
danger of traumatism I thought it best not to repeat the syphoning off of the 
gastric contents, as there was a risk in repeating the haemorrhage. There was no 
evidence of hysteria in the case. The diagnosis of gastric ulcer was made. 

Treatment. — Liquid diet, rest in bed, and bismuth gave quite some relief. 
When solid food was tried the gastric pain returned. 

Prognosis and Course. — Great care should be taken before giving a 
positive opinion concerning the outcome of gastric ulcer. If the condi- 
tions that induced the disease can be modified, then a chance for recovery 
exists. These cases, as a rule, do badly unless placed under the strictest 
supervision of a trained nurse. Such cases require treatment in bed, rather 
than ambulant treatment. Years of patient treatment may be required 
before positive benefit is secured. 

The prognosis depends on the above conditions. The disease is chronic 
and may cause death. 

Treatment. — Such cases do well by having a change of air. These 
children should not be permitted to attend school, and the same applies to 
the workshop, if the child is working. Sea bathing and cold sponging of 
the body, followed by friction, is very beneficial. A rigid liquid diet, con- 
sisting of peptonized milk, zoolak, soup, broth, and strained gruel, with an 
occasional change to cocoa, should be allowed. Fruit may also be permitted. 
This treatment must usually be carried out for months before recovery may- 
be expected. 

Cyclic Vomitixg. 

A great many writers report attacks of vomiting occurring at irregular 
or regular intervals of weeks or months which are termed cyclic vomiting. 
They claim that these attacks are not dependent on acute gastric disturb- 
ances, but are simply explosions due to latent or possibly nervous conditions. 
As a rule, we have such attacks in cases of acidosis. More often these attacks 
of so-called cyclic vomiting are associated with recurrent attacks of appen- 
dicitis. A blood examination should be made (see article on "Appendi- 
citis") . so that we can exclude appendicitis as a cause of the cyclic vomiting. 
(See article on the "Significance of Vomiting/' page 71.) 



236 DISEASES OF THE STOMACH. 



Dyspeptic Asthma. 

Peripheral irritation of the terminal filaments of the pneumogastric 
nerve frequently causes dyspeptic symptoms, which result in asthmatic 
attacks similar to those found in adults. A case of this kind came under 
my care in which fermentative conditions in the stomach caused pressure 
on the diaphragm and gave rise to asthmatic attacks. 

A well-nourished boy, 9 years old, was referred to me by Dr. H. Jarecky. He 
had attacks of coughing, wheezing, and slight cyanosis. The hands and feet were 
cold. The tongue was coated; the stomach distended with gas and very tympanitic 
on percussion. The asthmatic attacks were caused by the distention and pressure 
on the diaphragm, and disappeared when a rigid diet and a laxative were given. 
The boy suffered in addition with rheumatism. 



CHAPTEE IV. 
DISEASES OF THE INTESTINES. 

Infant Stools. 

Meconium. — The first discharge from an infant's bowels is called 
meconium. It has a greenish-brown color; at times it resembles ink in 
color. It is composed of epithelial cells, bile, cholesterin crystals, and 
partly digested amniotic fluid. Meconium has no odor. It is usually acid in 
reaction. The color of the infant's stool changes after a few days of ma- 
ternal or bottle feeding. 

As soon as the exclusive milk diet is changed to the mixed diet we then 
lose the characteristic infantile stool, and it resembles more that of an adult, 
though remaining softer and thinner throughout infancy. The stools be- 
come darker in color, assume the adult odor, and have more varieties of 
bacteria than those previously mentioned as found in the stool of a milk 
diet. 

A new conception of the various food elements shows that the opinion 
of ten years ago regarding the dangers of high fat has been modified, and 
the possibility of a protein or casein element being the disturbing factor 
suggested. Modern science has proven beyond a doubt that one reason why 
the fat element or casein disagrees is due to the presence of milk sugar; 
hence we today regard the carbohydrate and salt as the disturbing element 
in many cases, rather than the fat or casein. 

Finkelstein, of Berlin, has proven that in atrophic and marasmic 
infants in which there is a constant decomposition associated with fever and 
undigested stools we can modify the nutrition and restore faulty metabolism 
by omitting the addition of sugar or salt. The most important point, 
however, is that we can feed a very large fat and protein food, such as casein 
milk, described in the chapter on Faulty Metabolism, without causing 
gastric disturbance. 

The stool of a nursling or an infant on a human breast should be 
yellowish in color, smeary or pasty-like in consistency, and have an acid 
reaction. Normal yellow stool of a breast-fed infant contains bilirubin. 
Hydrobilirubin is associated with bilirubin after several weeks. 

Not infrequently during the first three months, normal infants fed 
exclusively at the human breast will have several stools a day. They may 
be green, watery, contain mucus, or appear lumpy. Such infants thrive, 
gain in weight, sleep well, and are apparently healthy. The cause of such 
peculiar stool has not yet been determined. They may be caused by 
maternal influences. Such stools are more frequent whilst the mother is 
menstruating. These stools should by no means be regarded as due to a 

(237) 



238 DISEASES OF THE INTESTINES. 

pathological condition, for we all can notice how this condition will 
regulate itself; even though greenish stools persist for several weeks, by no 
means should we change the food, but continue the breast if at all possible 
for the first three months. 

In no branch of pediatrics has so much progress been made in recent 
years as in the study and interpretation of infant faeces. The more we study 
infantile metabolism, the more we find that an intimate relationship be- 
tween internal secretions, on the one hand, and properly modified food, on 
the other hand, must exist. 

Modern views concerning the nature of curds in the stool have de- 
cidedly changed since the studies of Czerny and Keller. What formerly was 
believed to be casein curds is now proven by chemical analysis to consist 
principally of fat, but there are large, tough curds which are composed of 
casein in which fat is intermingled. The small, soft curds, however, some of 
them lentil-shaped or resembling round or flattened particles of compressed 
butter, consist chiefly of fatty acids and calcium soap in addition to a low 
percentage of protein. 

Talbot describes a simple test which will easily differentiate a casein 
curd from a fat curd, by placing the supposed curd in a 10 per cent, for- 
malin and allowing it to stand from four to six hours. If casein the curd will 
harden ; if fat it will become soft. 

Langstein, 1 speaking of the white faeces, regards the same as due to a 
faulty assimilation and signifies the beginning. of a disturbance of metab- 
olism. Thus, such white faeces may be due to a deficiency of the biliary 
secretion, but there also may be a disturbance in the intestine; Czerny and 
Keller regard the cause of the white faeces as due to the presence of calcium 
soap. 

Jafre, Gerhardt, and Zoja in a series of examinations have shown that, 
when urobilin and bilirubin are absent, the derivatives of the bile-pigments, 
such as urobilinogen, may be present. This latter substance is a reduction 
product of urobilin. Urobilinogen is constantly noted in alkaline solutions, 
but is transformed into urobilin in an acid solution. 

Normal and healthy children, such as those fed on human milk, give a 
negative urobilinogen reaction in the urine. On the other hand, artificially 
fed infants give a strong urobilinogen reaction in the urine. The reaction 
is very strong in cases of occlusion of the common bile-ducts, so that this 
reaction is of great service in the differentiation of duodenal catarrh in 
infancy. 

One of the reasons for the presence of the large curds is the absence of 
hydrochloric acid, which acid when entering the duodenum stimulates the 
flow of pancreatic juice. 2 



1 Langstein : Salkowsky's Festschrift, 1904. 

2 Fisher: "Physiology of Alimentation," 1907. 



STOOLS. 239 

Reaction of Stools. — Eeaction of stools in diarrhceal disease and in 
health is chiefly acid, or, next in frequency, neutral. Alkaline stools are 
rare. Grass-green stools, usually acid, are seen in the early stage of 
dyspeptic diarrhoea. The color varies from a pale greenish yellow to grass 
green, owing to improper food. 

The reaction depends on the presence of lactic acid, the source of which 
is the milk sugar. The only gases present are H and C0 2 . According to 
Escherich, H 2 S and CH 4 , to which the odor of adult stool is due, are not 
present. There are no special albuminoids peculiar to woman's milk. 
Those existing in woman's milk seem to be entirely absorbed. Peptone 
exists in trifling amount. Sugar is not present. Pancreatic ferment is 
absent, and sometimes traces of pepsin have been found. Mucus is always 
present in considerable quantity; also columnar intestinal epithelium. 

In the stool of nurslings large quantities of lactate of lime can be 
found; so also we frequently find oxalate of lime, depending on the quan- 
tity of oxalate of lime ingested. Ufflemann has noted the presence of 
bilirubin crystals in the stools of nurslings in perfect health. 

Quantity of Faeces. — The quantity of fasces varies, but it has been 
found that 100 grams of milk food will produce about 3 grams of faeces, 
according to Baginsky. This is a vital point, but I have found it very 
difficult to determine, for in most cases the napkins of the infant are 
soiled with urine plus the fasces, thus adding to the gross weight. 

Green Stools. — The green color of stool is caused by an abnormal 
oxidation of bile-pigment in which bilirubin is changed into biliverdin by 
means of an oxidase. 

Typical green stools can be produced by giving an infant two or three 
grains of bicarbonate of soda ; the soda must be given for a few days. This 
explains Pfeifier's alkaline theory. Typical green stools can also be pro- 
duced by giving small or large doses of calomel. If, after having given 
bicarbonate of soda and produced green stools, we give diluted hydrochloric 
acid in 5- to 10- drop doses, the yellow color will reappear in a few days. 
Ehubarb will also produce a yellow stool. 

Stools which are pale yellow when discharged, and which afterward 
become green, are often seen in disease. They may be themselves neutral 
or alkaline in reaction; this latter may, however, depend on the admixture 
of urine. An excess of bile may often cause very green stools. 

Wegscheider has shown that the green color is the result of preformed 
biliverdin. The condition in the intestine, upon which the transformation 
of bilirubin into biliverdin depends, has been generally regarded as one of 
acid fermentation. 

Pfeiffer's experiments 1 show this former opinion to be wrong. He 



1 "Verdauung im Sliuglings-alter bei Krankhaften-Zustanden," Jahrbuch fiir 
Kinderheilkunde, B. 28, page 164. 



240 DISEASES OF THE INTESTINES. 

found that none of the acids formed in such fermentation — lactic, acetic, 
butyric, propionic, etc. — added to yellow stools outside the body turned 
them green, but that they made them deeper yellow. But dilute alkaline 
solutions added to fresh yellow stools turned them green after an exposure 
of thirty to sixty minutes, and strong solutions turned them, first, brown; 
later, after exposure to air, intense green. 

Casein in high and low percentages has decided therapeutic properties. 
It increases the intestinal secretion which amounts to about one quart 
daily. It has an alkaline reaction; hence acts antagonistic to pathological 
acidity and thereby arrests fermentation. It is possible therefore to modify 
intestinal fermentation associated with putrefactive stools by omitting 
sugar and salt, reducing the fat, but chiefly by increasing the casein. 

When milk sugar is added in large quantities to food, it results in a 
primary irritation of the epithelium of the intestine, resulting in acid 
fermentation, and this latter prevents new epithelium from forming. When 
this carbohydrate element (milk sugar) is reduced the symptoms are 
immediately modified, and when the milk sugar is discontinued the casein 
lumps quickly disappear from the stool; in addition thereto the stool 
assumes a more solid consistency. 

Casein Masses or White Curds. — The coarser lumps of casein or so- 
called casein curds will be described later on. The small casein curds 
consist chiefly of fat. Casein is not nearly as common an ingredient of 
faeces as is supposed. As far back as 1878 Widerhofer doubted that these 
masses were really casein, but believed them to be fat with epithelial 
remains. Adler maintains that it is wrong to call a substance casein be- 
cause it responds to heat, biuret, Heller, and other protein reactions. 

Casein masses or casein lumps are frequently found in infants whose 
intestinal tract had been thoroughly emptied, and where the diet consisted 
of whey. It is well known that the casein masses consist chiefly of 
undigested remains of casein together with fatty acids and alkalies (Selter). 
The nucleoproteins of the intestinal secretion and the nucleoalbumins of 
the bile give a similar reaction. When milk has been withheld for a 
number of days watery discharges in enterocolitis will also give a positive 
protein reaction in the stool, due to casein masses. The principle of butter- 
milk feeding lies in the transformation of the casein into casein lactate. 

When milk is deprived of fat and casein, the result is whey, and if 
this whey is fed to an infant we frequently have casein curds in the stool. 
These curds consist of saponified fats and numerous bacteria. The protein 
reaction does not come from casein, but from the intestinal secretion, 
whereas the fatty acids and saponified fats are due to the sugar in the 
whey. 

Intestinal experiments at Finkelstein's clinic, reported by Meyer and 
Leopold, show that when the food contains a higher percentage of sugar 



STOOLS. 241 

than the infant can assimilate the result will be so-called casein masses in 
the stool. That this view is correct is proven by the fact that the moment 
the sugar element is reduced casein particles gradually disappear. This 
fact will be still more impressed when we note that with the reduction of 
the sugar we can increase the percentage of casein, thus showing a higher 
tolerance for casein, after we reduce the carbohydrate element. 

Protein. — The protein of milk is so thoroughly absorbed that only 
small traces of it can be found in the faeces. 

Albuminous decomposition and its products — tyrosin, indol, phenol, 
and skatol — are not found in milk faeces. Lactic acid, acetic acid, formic 
acid, and other fatty acids are present, causing the acid reaction. 
Von Jaksch found a saccharine ferment in the faeces of children. Baginsky 
found a peptonizing ferment also in infantile faeces. Escherich 1 says: "If 
albuminous decomposition with very foul offensive stools exists, albumins 
should be withheld from the diet and carbohydrates, such as dextrine foods, 
sugar/ and milk, given. If acid fermentation is present with sour, but not 
offensive stools, carbohydrates are to be withheld and an albuminous food 
such as animal broths, bouillon, peptones, etc., given. In the decomposition 
of milk, the sugar of milk, and not the casein, is usually broken up." 

Sugar. — If the sugar is too low, the gain in weight is apt to be slower 
than when furnished in proper amount. The symptoms indicating an 
excess of sugar are : colic or thin, green, very acid stools, sometimes causing 
irritation of the buttocks; sometimes there is regurgitation of food and 
eructations of gas. 

Artificially fed children excrete hydrobilirubin constantly. Whitish 
stools are usually associated with atony, also with various types of mild 
dyspepsia. In dyspeptic stools we are apt to find undigested casein or 
saponified fats. Scrambled egg stools frequently contain particles of undi- 
gested casein and fat. 

Fat Diarrhoea.- — This condition is primarily due to an imperfect func- 
tion of the bile as well as to the abnormal state of the pancreatic secretion. 
In such conditions as tuberculosis of the mesenteric glands and in severe 
enteric catarrh we are apt to find very fatty stools. According to Biedert 
and Demme, who have devoted considerable study to this subject, in some 
children the faeces showed 50 to 60 per cent, of fat, whereas the normal 
percentage in ordinary faeces varied from 14 to 25 per cent, (which is the 
normal quantity, according to Ufnemann) . 

Excess of fat is indicated by the frequent regurgitation of food in 
small quantities, usually one or two hours after feeding. Sometimes an 
excess of fat causes very frequent stool nearly normal in appearance. In 



1 Jahrbuch fur Kinderheilkunde, "Beitrage zur Antiseptischen Behandlungs- 
methode der Magen-Darmkrankheiten des Sauglingsalters." 

16 



242 DISEASES OF THE INTESTINES. 

some cases the stools contain small; round lumps somewhat resembling 
casein, but really masses of fat. 

Blood in Stools. — Blood from the stomach or small intestine frequently 
gives the stool a black color resembling tar. Thus, a practical point in 
Boas's "Diagnostik der Magen- und Darmkrankheiten" is that, the brighter 
the color of the blood, the lower down near the rectum and anus must the 
pathological lesion be looked for; the darker the blood, the higher up must 
the cause be sought; e.g., the diseased condition exists in the stomach, 
duodenum, or jejunum, etc., if the stool contains black blood. If the 
corpuscular elements of the blood are wanting, then only the presence of 
blood can be positively diagnosticated by either a microchemical examina- 
tion or by means of the spectroscope. The presence of red blood-corpuscles 
must always be regarded as a pathological factor. 

Brown Stools, Muddy Stools. — A brown stool in an infant is frequently 
caused by a diet of animal food or by a diet principally of broth. These 
stools have no distinct consistency nor reaction. In dyspeptic diarrhoea or 
in some forms of enterocolitis we have very offensive stools and they 
resemble muddy water; with the latter there is considerable flatus during 
each movement. 

Brown stools may be due to changed biliary pigment and to drugs: 
e.g., bismuth causes the well-known dark stool. So also tannic acid and 
all iron salts give the dark stool, which varies from a deep brown to a 
black color. 

Mucus. — Mucus is always present in all healthy stools and is so well 
mixed with the stool that it does not appear as mucus to the naked eye. 
Any appearance, therefore, of mucus easily visible should be regarded as 
abnormal. Mucus is present in every form of intestinal disease: very 
abundant in inflammatory conditions affecting the large intestine, more so 
than in those affections of the small intestine, and especially so in inflam- 
matory conditions of the colon, both acute and chronic. 

Jelly-like masses or shreds of mucus, and cases where the stool con- 
sists chiefly of mucus, show that the affection is confined to the lower 
portion of the colon or that it is located in the rectum. 

Long shreds of mucus, frequently resembling false membrane, are 
often found in catarrh of the large intestine. If the shreds of mucus are 
intimately mixed with the stool, then we must look for the lesion quite high 
up, and if it comes from the small intestine it is usually stained from bile. 
If the lesion is low down the mucus is not intimately mingled with the 
stool. 

White or Light-gray Stools. — These stools usually are of a putty-like 
consistency, sometimes like dry balls on a diaper; sometimes they appear 
like ashes. Usually they are very offensive, consisting principally of fat. 
There is scarcely a trace of bile, or the latter may be absent altogether. 



BACTERIA OF THE INTESTINES. 



243 



Scybalous Stools. — These are hard, dry, usually round masses in which 
the intestinal lubricant is absent. These stools are usually accompanied by 
flatulence. From their stagnation in the colon the gas bacteria cause a 
chronic distention and enlargement of the abdomen. 

Dyspeptic Stool. — The first change noticed in the d}'speptic stool is the 
increase of fat. Often the stool is quite green and contains small pieces, 
of yellowish-white color, which vary in size from that of a pinhead to the 
size of an ordinary pea. Hitherto, from their color, they were supposed to 
be casein lumps. Wegscheider has taught us that they consist principally 
of fat. Baginsky has shown that large colonies of bacteria are contained 




Fig. 62.— Ba< 



"oli Commune. 



in these lumps of fat. Frequently they are so numerous that it looks as 
though the stool were composed only of these cheesy lumps. They can be 
easily differentiated from real casein lumps by their solubility in alcohol 
and ether. 

Bacteria of the Intestines. 

There are a great many bacteria found in the intestines. These are 
present in a normal infant, as well as in an infant suffering from a gastro- 
intestinal disorder. A great many of these bacteria are, therefore, non- 
pathogenic. Miller, who carefully studied the various micro-organisms in 
the mouth, found that most of them could again be found in the intestinal 
canal. 

Moro describes the bacillus acidophilus, which is a constant inhabitant 
in both the small and large intestine. It has the property of coagulating 
cows' milk, but not human milk. The bacillus bifidus communis will chiefly 



244 DISEASES OF THE INTESTINES. 

be found in the intestine of a breast-fed infant. It is anaerobic. The bac- 
terium coli communis and bacterium lactis aerogenes are largely concerned 
in the formation of lactic acid. The colon bacillus generates indol as well. 
The role played by bacteria is not yet well understood. It is quite possible 
that, instead of doing harm, some bacteria do good. This is especially 
noted when all bacteria are destroyed by sterilization, and bacteria-free milk 
is fed. Such prolonged feeding may result in scurry. 

Diarrhoea. 1 

By diarrhoea is meant too frequent stools. This increased peristalsis 
is usually due to some specific cause. Infants on a liquid diet are more 




Fig. 63. — Bacterium Lactis Aerogenes. 

prone to loose evacuations than older children on a solid or semi-solid diet. 
Children suffering from rickets or atrophy infantum, or any form of mal- 
nutrition, are more prone to the development of diarrhoea. The cause of 
the bulk of the cases of diarrhoea seen by me during the last fifteen years, 
in one of the largest dispensaries of New York City, was bottle-feeding. 
Out of 1000 cases of diarrhoea 900 were bottle-fed and lived amid poor 
hygienic surroundings. In 90 cases the children were breast-fed, but there 
was a disturbance during lactation. This disturbance was pregnancy, 
menstruation, tuberculosis, or syphilis in the mother, or prolonged nursing 
with deficient fats and protein. 

In 10 cases there was no assignable cause excepting the subnormal con- 
dition of the body due to an excess of midsummer heat. 



1 See also chapter on "Intoxication." 



DIAHRHCEA. 245 

Contaminated Milk. — Impurities, such as bacteria, filth, and chemical 
products due to fermentation, can easily cause diarrhoea. In my article on 
"Bacteria in the Intestine," I describe the two most frequent varieties of 
bacteria which are normally found in the intestine. They are the bac- 
terium coli and the bacterium lactis. These bacteria frequently assume a 
virulent form under certain conditions. They very often cause diarrhoea. 
Other bacteria, such as the streptococci, can be introduced in cows' milk. 
A diseased udder in the cow will frequently secrete pus in addition to milk. 
Such milk must necessarily cause trouble when introduced into the in- 
fantile stomach or bowels. 

Improper Diet for Older Children.— We frequently see people who 
think it wise to give their children, regardless of their age, a bit of any- 
thing from the table. Eaw fruits and raw vegetables, cabbage, and pickles 
are given regardless of the consequences. In studying the dietetic sins com- 
mitted by the parents of children in two dispensaries located in different 
sections of New York City, I found the following conditions : — 

One hundred children between the second and sixth years of age 
living in tenements apparently healthy; 80 received a taste of beer or a 
drop of whisky diluted with water every day. In some families the children 
received as much as a wineglassful and more of beer with each meal. Such 
imprudence is frequently a distinct factor in the causation of diarrhoea. 

Nervous Diarrhoea. — The influence of fright or excitement is the best 
example of diarrhoea due to nervous influence that can be given. When 
caused by a nervous influence the fasces contain mucus, and there is usually 
an explosive stool. It is a form of exaggerated peristalsis. Chilling the 
surface of the body frequently provokes diarrhoea. 

Diarrhoea as a Symptom of Disease. — Nature's method of eliminating 
poison is frequently seen when a diarrhoea commences in the course of an 
acute infectious disease. Toxic products can best be eliminated by the 
emunctories, and the intestines are one of the most valuable agents for 
eliminating poison from the body. The diarrhoea of typhoid fever, sum- 
mer complaint, dysentery, and ileo-colitis have been described in their 
respective chapters. 

Treatment. — Seek the cause and if possible remove the same. If .a 
dietetic error has caused the diarrhoea, then a good dose of castor-oil should 
be given. In all events a good cleansing should begin the treatment. Mist, 
rhei et sodas in teaspoonful doses can be given several times to cleanse the 
gastro-intestinal tract. Several hours after the laxative has been given the 
rectum and colon should be flushed with hot water containing a teaspoonful 
of salt to each pint. The temperature of the saline solution should be about 
110° F. 

Bismuth in 3 to 10-grain doses, repeated every two hours, is our best 
remedy. 



246 DISEASES OF THE INTESTINES. 

I£ Mist, creta 2 ounces, 

one teaspoonful every two hours, is also valuable. 

Diet. — Stop all milk. Give whey and rice water thickened with potato 
flour or wheat flour. Give the white of egg several times a day; also cocoa 
and water. 

For Thirst. — Give 5 to 10 drops of diluted hydrochloric acid in a tum- 
blerful of boiled water (sterilized). This can be given ad libitum. 

Diluted phosphoric acid, 20 drops to a tumblerful of sweetened water, 
is a pleasant drink during fever. It is also stimulating. 

The charts on pages 247, 248, and 249 were kindly furnished to me 
by Dr. William H. Guilfoy, Chief of the Bureau of Statistics, Health De- 
partment, City of New York. 

Insolation (Heat-stroke; Sunstroke). 

This condition is most frequently seen in midsummer. It sometimes 
occurs in perfectly healthy children who are exposed to the direct rays of 
the midday sun. I have frequently seen cases of sunstroke in feeble chil- 
dren who were playing in the shade. Children with lowered vitality and 
convalescents from some severe illness, such as diphtheria or pneumonia, 
are more prone to be affected by intense summer heat. 

Pathology. — Intense cerebral hyperemia and an intense engorgement 
of the veins throughout the body are the usual lesions seen in this con- 
dition. 

Symptoms. — A child in apparently good health in midsummer will 
suddenly show intense fever. The temperature reaches as high as 104° 
or 105° F. in many instances. There is a corresponding increase in the 
pulse-rate. The pulse may be as high as 160 or 180. The face is usually 
flushed. The head is hot. There is a throbbing of the blood-vessels very 
apparent. The child may be unconscious and muscular twitchings may be 
noticed. In severe prostration there may be delirium and convulsions. 

The pupils are usually contracted, although they may be dilated, and 
the eyes intensely congested. Sometimes vomiting and diarrhoea may ac- 
company the symptoms above mentioned. 

The following illustrates the manner in which heat-stroke occurs in 
New York City : — • 

A child will awaken in a normal condition, eat its breakfast and play as usual. 
After several hours' hard playing and exposure to the sun's rays, the child will be 
exhausted. If a careless mother or nurse permits the child to continue its exposure 
to the direct midsummer heat, then prostration with the above-noted symptoms will 
be noticed. In some cases brought to my clinic, the head is hot and the hands and 
feet are cold. If the sunstroke takes place soon after feeding, then violent gastric 
symptoms usually occur. 



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DISEASES OF THE INTESTINES. 



Prognosis. — The prognosis depends upon the vitality at the time of 
sunstroke. We must differentiate this condition from meningitis. The 
suddenness of the attack following exposure to the sun will usually aid 
in making a diagnosis. The majority of cases seen by me recovered. Occa- 
sionally a fatal case was encountered, especially in bottle-fed infants. 




Fig. 67. — Insolation (Heat-stroke). Type of midsummer cases in New 
York City. (Original.) 

This infant (Fig. 67), brought to my clinic July, 1909, weighed 5 pounds 6 
ounces. He was a bottle-fed infant, reared on condensed milk. He was nine weeks 
old. Vomited after each feeding, had greenish, mucous, sour-smelling stools, every 
half-hour and oftener. There was eczema between the thighs from excoriation and 
acid stools. The child weighed 6% pounds at birth, and was a full-term baby. 

The child was pulseless. The extremities were cold and covered with a clammy 
perspiration. The temperature was subnormal — 97° F. The fontanel was de- 
pressed. The heart sounds were barely audible. The mouth, tongue, and lips were 
very dry; food and water were refused. Spirits of camphor, 5 drops, was injected 
hypodermically ; a mustard foot-bath was ordered. The child died fifteen minutes 
later. 



DYSENTERY. 251 

Diagnosis. — Cholera infantum, marasmus, due to malassimilation of food; im- 
proper food to commence with. Extreme heat caused heart-failure and general pros- 
tration. 

Treatment. — A tub-bath, temperature 90° F., gradually decreased to 
70° F., duration five minutes, is advisable. An ice-bag should be applied 
to the head. If consciousness has been restored, the child should be al- 
lowed to rest; if not, then we can restore the circulation to relieve cerebral 
hyperemia by giving a mustard foot-bath for several minutes until the skin 
is reddened. The rectum and colon should be flushed with a hot saline 
solution at a temperature of 110° F. ; this will stimulate diuresis besides 
cleansing the bowel. One-drop doses of aromatic spirits of ammonia with 
water may be given every fifteen minutes. 

If the child can swallow then : — 

Ifc Bromide of sodium 10 grains 

Chloral hydrate 3 grains 

should be given to a child 5 years old. This can be repeated every hour 
until a sedative effect is produced. In some cases (comatose) it may be 
advisable to inject per rectum : — 

IJ Bromide of sodium 15 grains 

Starch water 1 ounce 

Cold water should be given by mouth, with several drops of diluted 
hydrochloric acid. Peptonized milk, thin soups, and broths may be given 
every few hours. Liquid peptonoids can be tried if food is rejected. 

Dysentery (Ileo-colttis). 

The lower portion of the intestine is frequently the seat of an infection 
by pathogenic bacteria. 

Pathology. — As this condition frequently follows severe milk infection, 
the pathogenic lesions are necessarily the same, although in a more ag- 
gravated form. In addition to the hyperemia of the mucous membrane 
there may be a small haemorrhage in the mucosa or submucosa. The mucous 
membrane is very deeply pigmented, frequently being of a purplish line. 
The solitary lymph follicles along the colon are swollen. The discharge of 
mucus is tinged with blood, and not infrequently the amoeba coli described 
by Losch, or known as the amoeba dysenterim, described by Councilman and 
Lafleur, can be found. "It is a unicellular, protoplasmic, motile organism 
from 10 to 20 micro-millimeters in diameter, and consists of a clear outer 
zone (ectosarc) and a granular inner zone (endosarc), containing a nucleus 
and one or more vacuoles." Multiple abscesses are frequently found. "The 
ulcer first begins as a small papule, the upper part of which sloughs off, 
leaving a grayish-yellow ulcerating surface." 



252 



DISEASES OF THE INTESTINES. 



Diphtheritic dysentery, sometimes known as the croupous variety, is 
a catarrhal form of this same condition previously described, in which the 
infection can be traced to an invasion of the Klebs-Loeffler bacillus. The 
ulcerations are covered with a pseudo-membrane, and the pathogenic con- 
ditions are as previously described. 

Bacteriology. 1 — There are two groups of bacilli which are responsible 
for the development of various types of epidemic dysentery: — 

1. The true Shiga group. 

2. Group of mannite fermenters. 

The latter group is divided into two types : — 



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Fig. 68. — Bacillary Diphtheria of the Colon or Diphtheritic Colitis, a, 
Necrotic tissue containing bacilli, b, Gland with necrotic epithelium, d, 
Connective tissue, e, Degenerated and exfoliated epithelial cells, f, Bacilli 
in the lumen of the gland, g, Bacillary deposit beneath the epithelium. 
h, Nests of bacilli in the connective tissue. X 300. (Ziegler.) 



(a) Fermenting mannite alone in peptone solution. 

(b) Fermenting maltose and saccharose. 

Symptoms. — The attack is usually ushered in with diarrhoea. There 
is also considerable straining with each stool. At first the stools contain 
particles of faeces, and as the disease progresses they become more liquid 
and contain mucus and blood. Some authors describe the stool as con- 
taining shreds that resemble the washings of raw meat. The face shows 
a very anxious expression. There is extreme pallor. The child appears 
prostrated. The pulse is accelerated and very feeble. The abdomen is 
distended, especially over the colon. Vomiting is a rare symptom. Unless 
treatment is rapidly instituted the child will fail in strength and may die. 



1 The Journal of Medical Research, vol. xi, No. 2, May, 1904. 



DYSENTERY. 



253 



Such children usually sleep with the eyes half open and show evidences 
of collapse. The rectum may protrude, especially when there is a distinct 
relaxation of these parts. Cold, clammy perspiration is usually found, 
especially on the head. The extremities are cold. Convulsions appear in 
the severer forms of dysentery. In the diphtheritic variety the temperature 
and pulse resemble a case of true diphtheria. The stool, in addition to- 
mucus and blood, may have particles of pseudo-membrane. Toxaemia can 
usually be seen by its effect on the heart and pulse. The urine may contain 
albumin. Where the toxaemia progresses, convulsions may set in and death 
result from cardiac paralysis. 




Fig. 69. — 'Croupous Enteritis, Diphtheritic Colitis, two-thirds 
natural size. (Langerhans.) 

Diagnosis. — The bloody mucus and watery stools seen in this con- 
dition, associated with tenesmus, will usually aid in eliminating acute 
milk infection. In gastro-enteritis and entero-colitis there is usually a 
greenish, spinach-like stool, or a brown, muddy stool having a very foetid 
odor. The stools in dysentery are smaller in quantity. Both the diph- 
theritic and the amoebic forms of dysentery are rare in children. 

Prognosis.. — If this disease is epidemic, or if it occurs in children 
having bad sanitary surroundings, then the prognosis is bad. The dura- 
tion of an acute attack is usually about five or six days. The prognosis 
is good when the diarrhoea and blood gradually disappear. The main 
point to remember is that the heart must be sustained by proper nutrition, 
and we should try to counteract the toxaemia by proper stimulation. 



254 DISEASES OF THE INTESTINES. 

Treatment. — The same hygienic measures described in the chapter on 
"Food Intoxication" apply equally as well here. ^Impress the mother 
or nnrse that unless she carries out the directions minutely, the child has 
little chance of recovery. 

Dietetic Treatment. — The dietetic management will consist in leaving 
out milk. Whey, barley water, rice water, or toast water may be given. 
Mutton broth thickened with rice may be given to an older child. Whisky 
and water should be given from the beginning. It is not too much to give 
2 to 4 ounces of whisky per day. The physician should order the amount 
of whisky by telling the mother or nurse to give % drachm or more well 
diluted with barley or rice water, every half -hour. 

Coffee is a valuable cardiac stimulant. Champagne may also be given. 

Local Treatment. — The physician will be most successful who places 
his patient in bed, regulates the diet, cleanses the intestinal tract, and 
relieves the tenesmus by local treatment. The heart should be supported. 
The strength must be sustained with nutrition and the flushing of the bowel 
should be performed as soon as possible after a stool is evacuated. 

Warm chamomile tea should be used to cleanse the colon and rectum. 
This should be injected at a temperature of 100° to 105° F., with the aid 
of a small rubber catheter. This can be followed by an injection of 1 
ounce of sterile water containing 2 grains of nitrate of silver. Yery bland 
injections, such as 

Ifc Raw starch 1 teaspoonful 

Chamomile tea 1 quart 

Laudanum 10 drops 

injected at a temperature of 100° F., will soothe the rectum and frequently 
relieve tenesmus. I have successfully treated dysentery cases with the 
following : — ■ 

Ifc Argentum nitrate 6 grains 

Cocoa butter q- s. 

M. Form into twelve suppositories. 

I£ Oleoresin terebinthinae 12 grains 

Extract of belladonna 6 grains 

Extract of opii aquosa 1 grain 

Cocoa butter q. s. 

M. Form into twelve suppositories. 

Sig. : Insert alternately q. 3 hours. 1 

Sulpho-carbolate of soda, in doses of 5 to 10 grains, can be used 
several times a day. Bismuth combined with Dover's powder is frequently 
valuable. An ice-bag placed on the abdomen in the region of the colon will 
sometimes do good. Very cool injections of table salt and water are some- 
times of value when hot injections are not well borne. 

r As the nitrate of silver would oxidize the organic -matter contained in the 
second formula, the suppositories must be given at intervals of three hours. 



PELLAGRA. 255 

Pellagra. 

The etiology of pellagra is still obscure. Jos. Goldberger, 1 in an 
extensive study of this subject for our government, found that, first, this 
disease is essentially rural ; second, associated with poverty. While posi- 
tive data are not available as to the real etiological factor, be it insect 
transmission or diet, the impression prevails that canned goods, vegetables, 
and cereals, especially corn products, should be laid aside, and fresh milk, 
fresh eggs, and fresh meats used instead. In a study of an orphanage at Jack- 
son, Miss., of 211 orphans, 68, or 32 per cent., had pellagra. Practically 
all of the cases were children between the ages of 6 and 12 years. In a 
group of 25 children examined, under 6 years of age, there were 2 cases. 
In a group of 66 cases over 12 years of age, there was 1 case. 

The exempt group were found to subsist on a better diet than the 
affected group. In the diet of those developing pellagra, a small amount 
of meat and other animal protein food was found. A large part of the 
ration consisted of corn, sirup, and legumes. The inference may therefore 
be safely drawn, that pellagra is not an infection, but that it is a disease 
essentially of dietary origin. It may be caused, for example, by the ab- 
sence from the diet of essential vitamines. Meyer and Yoegtlin believe that 
the presence, in the vegetable food component, of excessive amounts of soluble 
aluminum salts is the responsible poison causing this disease. 

Symptoms. — The skin manifestations may either be a slight roughening 
or thickening of the affected skin, so that an urticarial or erythematous 
flush resembling erysipelas may be found. Other types are either cedema- 
tous or have an extensive desquamative dermatitis. In fatal cases marked 
sloughing of the skin is noted. Glossitis and stomatitis are common symp- 
toms. The bowel disturbance is usually diarrhceal in character. Now 
and then a case will appear in which constipation exists. 

Lorenz 2 has made a study of the cerebrospinal fluid in pellagra. He 
finds that: 

1. A lymphocytosis of the cerebrospinal fluid does not occur in uncom- 
plicated pellagra. 

2. Globulin excess of the spinal fluid is only occasionally observed. 

3. Lange^s colloidal gold chloride test is uniformly negative in 
pellagra. 

4. The Wassermann is negative with a few exceptions. In this in- 
vestigation the exceptions were moribund cases which gave weakly positive 
reactions with blood-serum. 

5. The spinal-fluid findings would seem inconsistent with a concep- 
tion that pellagra is an infectious disease of the central nervous system. 

x The Treatment of Pellagra. Reprint No. 218 from the Public Health 
Reports, September 11, 1914. 

* Lorenz, W. F., special expert, United States Public Health Service, and 
director Wisconsin Psychiatric Institute. 



256 DISEASES OF THE INTESTINES. 

It is very evident from Lorenz's examination that we are dealing with 
some local disturbing, agent in which the gastro-intestinal canal is the part 
affected. When one considers that the bulk of cases appear in those districts 
in which the food is largely made up of preserved, canned, and desiccated 
or packed meats, then the diet must be looked upon as probably responsible 
for the symptoms noted. 

Treatment. — Treatment consists in reducing the food that probably 
causes the disease, and adding fresh meat, milk, eggs, vegetables, and legumes 
to the diet. The diet advised in the treatment of scurvy is similar to that 
advised in the treatment of this condition. Arsenic, atoxyl and salvarsan 
have been recommended, but one and all found wanting. Small doses of 
quinine, iron and strychnine, codliver oil, olive oil, fresh butter and fresh 
cream will aid in restoring normal conditions. To relieve the diarrhoea a 
dose of castor oil followed by 5- to 10- grain doses of bismuth or tannigen 
should be given. 

Food Intoxication (Toxicosis; Choleka Infantum; 
Acute Milk Infection). 

For many years we have been taught that the ingestion of bacteria 
in milk causes diarrhoeal diseases. Some authors have found one or more 
million bacteria in 1 cubic centimeter of ordinary milk; other specimens 
have contained only 50 thousand bacteria in 1 cubic centimeter. In count- 
ing these bacteria, the harmless and harmful varieties are not separately 
considered. In other words, bacteriologists merely consider germs. There 
are many forms of bacteria which normally inhabit the intestine. That 
these innocent bacteria assume a virulent form under certain irritated con- 
ditions has been suspected. The bacillus of Shiga has been found in 
many cases of intestinal catarrh with diarrhoea and symptoms of intoxi- 
cation. There are equally as many cases of the same type in which no 
Shiga bacillus can be found. One must assume, therefore, that there are 
other factors equally as important as bacteria causing this condition. 

It has been possible to reduce one or more million bacteria in each 
cubic centimeter of raw milk to 50 thousand bacteria per cubic centimeter, 
by subjecting the milk to steaming at a temperature of 140° F. for ten 
minutes. We know that the toxins generated by some bacteria are more 
deadly in their action than the bacteria themselves. Such toxins can with- 
stand a temperature of 300° F. without destruction. 

To Finkelstein belongs the credit of having shown that bacteria do not 
enter into the causation of this disease, but that the faulty assimilation 
of fat and sugar is responsible for this condition. Finkelstein proves this 
by relieving the symptoms when fat and sugar are withdrawn from the food, 
and when the protein element is increased. This he does regardless of the 
presence or absence of bacteria. 



INTOXICATION. 257 

In bottle-fed children, especially among the poorer classes, acute milk 
poisoning is frequently seen during the summer months. This is due 
mainly to the chemical or toxic product developed in the milk. The heat 
of the summer rapidly decomposes milk, and large quantities of bacteria 
multiply and generate their toxic products. When such milk is fed to 
infants they show the effect of the toxin very rapidly. Park found that 
when milk was first received from the farms it contained from 10,000 to 
20,000 bacteria in each cubic centimeter. On the second day the bacteria 
had so increased that there were between 10,000,000 and 30,000,000 per 
cubic centimeter. 

Summer diseases, particularly entero-colitis and cholera infantum, will 




Fig. 70. — A Case of Acute Milk Poisoning Having Vomiting, Diarrhoea, 
Mucous and Bloody Stools, General Emaciation, Acute Cholera Infantum, 
and Dysentery. (Original.) 

appear just as readily in breast-fed children who are improperly managed 
as in bottle-fed children. 

Pathology. — There is extreme emaciation of the entire body affecting 
muscles and fat. The fontanel is depressed. The eyes are sunken. The 
elasticity of the skin is gradually lost; the skin hangs in loose folds. The 
body- resembles an advanced form of tuberculosis. Minute haemorrhages 
are found associated with intense congestion in the stomach and intestines. 
The evidence of catarrh is everywhere seen. There is an excessive secretion 
of mucus in the larger intestine ; in the colon ulcers will be found. 

Ashby and Wright describe a general distention of the net-work of the 
capillaries situated in the mucous membrane of the intestine. The same 
condition is found in the submucosa, in the villi, and between the tubules 
and crypts of Lieberkiihn. "The central portions of the solitary glands 
are softened, or, the softened portions having been discharged, the remains 
of the glands appear as sharply cut ulcers, although the sinuses of the brain 

17 



258 DISEASES OF THE INTESTINES. 

are found distended with blood. Occasionally cerebral anaemia may exist." 
Meningitis is rare. 

Bacteriology. — The enormous material at our command in this country 
gave the Eockefeller Institute an advantage in studying the pathogenic 
bacteria in this disease. It was found that the bacillus dysenterise (Flexner) 
is present in very many cases. Other investigators along the same lines 
have found the bacillus pyocyaneus (Cooper) a probable causative factor in 
this disease. On the other hand,. Finkelsteim. Eseherich, and Moro believe 
that the bacillus acidophilus is the causative agent. Other investigators 
believe the bacillus coli communis or the streptococcus to be the causative 
agent. Finkelstein and Meyer have shown that milk sugar in food can alone 
produce intoxication. When a high fat content is present, this naturally 
aids in the intoxication caused by the sugar. 

It is impossible to believe that bacteria per se are not at the root of the 
disease, and yet convincing. argument is offered by the German investigators 
to prove their claim: ~that the disease is one in which there is a dietetic 
error resulting in, first, a local ; and later, a general systemic disturbance. 

Causes. — The etiological factors can be briefly outlined as follows : — 

1. Food, improper quantity and quality of the same, be it breast-milk 
or hand-feeding. 

2. The most frequent cause is certainly improper bottle-feeding, 
wherein food unsuited to the infant's digestive abilities is continued, in 
spite of Nature's efforts to warn us, as frequently manifested by either 
vomiting or diarrhoea, or both. 

3. Milk from mothers suffering with tuberculosis or syphilis. Preg- 
nant, menstruating, and all anaemic women secrete such poor milk that 
gastro-enteric derangements are exceedingly common. 

4. The influence of the weather on digestion, especially the extreme 
heat of summer. 

Harry G., ten months old, bottle-fed, was brought to me with a history of 
vomiting, high fever, and diarrhcea. The temperature was 104° F. The stool was 
green and contained mucus and curds, and had a very foetid odor. The stools were 
as frequent as twenty in twenty-four hours. There was a great deal of flatulence, 
the abdomen was distended, and there was constant tenesmus. The mouth was 
dry, the tongue had a whitish fur coating, and in the mouth small patches of 
stomatitis could be seen. The tongue protruded constantly and when liquids were 
given they were taken ravenously. The mother stated that ordinary grocer's milk 
had been used, and that she believed the milk had turned sour "after a thunder 
storm." The diagnosis of acute milk infection was made. The stomach was washed 
by the use of 1 quart of saline solution. Two drachms of castor oil was ordered, 
and one hour later the rectum and colon were flushed with 1 quart of chamomile tea. 
All milk was stopped. No food was given for six hours. A bland diet of sweetened 
rice water and whey was then given in quantities of 4 ounces every two hours. As 
a stimulant, 15 drops of whisky was given with }4oo grain of strychnine every three 
hours. The child improved, and three days later 1 ounce of milk, with 7 ounces of 
rice water, was given every three hours. The milk was gradually increased every 
other day, and the rice water decreased. The child recovered. 



INTOXICATION. 259 

Symptoms. — The two cardinal symptoms are (a) vomiting, (b) diar- 
rhoea. In some instances the first evidence of this infection will be fever. 
The temperature may be as high as 103° to 105° F. There will be intense 
thirst. There is no appetite. The infant will refuse its bottle, and if 
forced to take it will immediately throw it off. Bile, mucus, and sour- 
smelling curd form the bulk of the vomit. The abdomen is usually dis- 
tended. There is a great deal of flatulence. The stool is watery and green- 
ish in color, with a very foul odor. When the diarrhoea continues for 
several days, the temperature may become subnormal and the infant's fore- 
head may be covered with a cold, clammy perspiration. The extremities 
are usually cold. The child will sink very rapidly, owing to the amount 
of exhaustion. The body is constantly drained by the diarrhoea. Unless 
the clinical picture is recognized and proper treatment instituted, the 
infant may sink into a coma and have convulsions, followed by death. 

The following case illustrates acute milk poisoning in an infant less than 1 
year old. The infant was bottle-fed and received the food daily, modified, from a 
milk laboratory. This food seemed to agree until the time of the present illness. 
The child was under the treatment of Dr. John Logan and Dr. J. Martinson, both 
of New York. The case was seen by me in consultation after several days' illness. 
The infant was vomiting and had greenish, mucous stools. There was severe tenesmus. 
The infant showed severe prostration and was apparently comatose. The fontanel 
was sunken. The pulse was very feeble. The circulation was poor and the extremi- 
ties cold. As no food was retained, in addition to the amount of toxin in the 
circulation, the heart's action became weaker and weaker. It was very difficult to 
rouse this child. In spite of high saline colon injections, the child died of exhaustion 
associated with general toxaemia. 

Diagnosis. — The diagnosis of this condition is extremely easy. It is 
usually aided by the clinical history. The disease usually occurs in sum- 
mer, although milk poisoning can take place during any time of the year. 

Differential Diagnosis. — Sunstroke may sometimes be confounded with 
cholera infantum, but the continued diarrhoea in cholera infantum, and 
its history, should aid in eliminating this condition as a factor. Asiatic 
cholera shows symptoms similar to cholera infantum. The presence of the 
comma bacillus in the stools will establish the presence of Asiatic cholera. 

An important point to remember is that very many diseases have 
symptoms resembling cholera infantum and must be carefully differen- 
tiated; for example, typhoid fever occurring in midsummer may simulate 
this disease and give rise to symptoms which greatly resemble cholera in- 
fantum. We occasionally see children .having diarrhoea, vomiting, and 
fever in whom on palpation a tenderness in the ileo-caecal region can be 
palpated. Such cases may have appendicitis and still show all the symp- 
toms of cholera infantum. 

The blood examination will aid in establishing the diagnosis of ap- 
pendicitis. In the latter condition we have a marked leucocytosis and a 
high polynuclear percentage. 



260 DISEASES OF THE INTESTINES. 

The prognosis depends on the infant, its snrronndings and the amount 
of infection, and the length of illness. An infant having good vitality and 
being given a careful diet and stimulation with proper hygienic treatment 
certainly has more chance than one left in the city amid poor surround- 
ings with faulty hygiene. 

Hygienic Treatment. — Before feeding is considered we must put the 
infant into the best possible surroundings, a clean room, clean linen, a clean 
bed ; in fact, all sanitary conditions must be perfect. If possible the infant 
should be placed on the roof of a house in the city, or out-of-doors in the 
country, both day and night. To place a case out-of-doors during the day 
is not sufficient. If sea air is obtainable, it is best to remove the child to 
the seashore, or at least insist om daily excursions. Cold bathing, or bathing 
in cold or lukewarm water, to which some sea salt has been added, has 
proven beneficial. 

Dietetic Treatment. — After the hygienic conditions are satisfactory, at- 
tention should be directed to the food. Knowing that this disease is caused 
by faulty feeding, the most important and therapeutic indication is the 
feeding. Liberal quantities of water sweetened with y 2 grain of saccharine 
to the pint should be given. Skimmed milk, or diluted skimmed milk, or 
junket made with skimmed milk is the best food for this condition. Butter- 
milk made from the lactic acid bacillus and skimmed milk should form 
the bulk of the diet. Eice or barley water sweetened with saccharine may 
be useful in controlling the diarrhoea. The intervals of feeding should be 
from three to four hours. The quantity should be reduced. If the infant 
had been getting 6- or 8- ounce feedings, the quantity should be reduced to 
4 or 6 ounces at one feeding. Lime water may be given liberally, several 
teaspoonfuls in one hour. Weak, cold tea may be given ad libitum. 

If the infant is breast-fed discontinue the breast at least twenty-four 
hours. If the acute symptoms of vomiting and diarrhoea have been stopped 
by appropriate treatment, then the breast may be permitted once every six 
or eight hours, the alternate feeding to consist of rice or barley water 
sweetened with saccharine. In other words, we must return gradually to 
milk feeding. If acute symptoms return when the breast-milk is given, then 
it is a question as to whether or no the breast should be entirely withheld. 

Antipyretic Measures. — Cold applications to the head and an ice-bag 
over the fontanel, cold towels changed every fifteen or thirty minutes over 
the abdomen, will tone up the nervous system in addition to reducing the 
temperature. I am a decided opponent to antipyretic drugs, and never use 
antipyrin or phenacetine, but invariably resort to hydropathic measures for 
the reduction of the temperature. Sponging of the body with alcohol and 
water is very grateful and refreshing, besides a good antipyretic measure. 
If cyanosis and cold extremities exist, then it is wise to resort to hot 
mustard baths to stimulate the circulation. 



INTOXICATION. 2G1 

Drug Treatment. — The tendency to constipation following a dose of 
castor-oil makes it a valuable remedy in all forms of diarrhoea. Bismuth is 
the sovereign remedy; I have used the subcarbonate, subnitrate, salicylate, 
and betanaphthol bismuth, and find the latter an extremely valuable prepara- 
tion. In doses of 2 to 5 grains every few hours, mixed with a little boiled 
water, it not only agrees very well with children, but seems to exert a heal- 
ing effect in that form of bacillary diarrhoea which is met with in the acute 
catarrhal gastro-enteritis. 

Salol in doses of 1, 2, and 3 grains, for each year respective^, is an- 
other valuable remedy; so also is resorcin, in doses of ^ to 1 grain for 
a child 1 year old, three or four times a day. It is advisable not to add 
sugar for sweetening, but only glycerine, the latter, however, in very small 
quantities, as it has a tendency to loosen the bowels. 

Tannalbin and tannigen in doses of from 1 to 10 grains seem to act 
well in some cases, poorly in others, but are well worth trying in those 
desperate cases in. which we change the drugs, if they are ineffectual. 

Hypodermic Medication. — In forms of collapse, where constant diar- 
rhoea has drained the system, it is a good plan when the extremities are cold 
to give hypodermic injections of 10 to 20 drops of whisky. Sulphuric ether 
can also be administered hypodermic-ally in the same dose as whisky. An 
intravenous injection of 1 pint of normal saline solution containing a 
drachm of adrenaline solution 1 : 2000 may be given. Another valuable 
stimulant is musk; 2 to 3 drops of tincture of musk administered hypo- 
dermically every hour will frequently rouse the circulation. 

When this form of treatment proves unsuccessful, and the condition of 
collapse continues, then a good plan is to resort to liypodcrmoclysis. This 
consists of introducing a long aspirating needle (previously sterilized by 
boiling) into the loose connective tissue of the abdomen, and allowing sev- 
eral ounces of the normal saline solution, containing about 7% grains of 
table salt to a pint of water, temperature 100° F., to flow in subcuta- 
neously. It is remarkable to note how much liquid can be introduced in 
this manner, and some of the most desperate cases of collapse will respond 
very rapidly. I have seen children who previous to this injection were 
pulseless suddenly brighten up, and within a few minutes show a distinct 
radial pulse. Too much care cannot be bestowed on the sterilization of 
every part of the apparatus, and the absolute cleanliness of the water to be 
used for this purpose. 

Rectal and Colon Flushing. — It is advisable to irrigate the colon and 
rectum by placing the child on its left side, introducing a flexible rubber 
tube anointed with carbolized vaseline. Having passed the external sphinc- 
ter, I invariably allow the water to flow into the rectum in order to balloon 
the same, and then continue to push the tube beyond the rectum into the 
colon. A little difficulty is sometimes encountered, owing to the spas- 



2G2 DISEASES. OF THE INTESTINES. 

modic contraction of the muscles, but if we wait a short time, using a little 
patience, the tube can easily be pushed into the colon. The method pur- 
sued is the same as described previously in irrigating the stomach, excepting 
that we do not seek to syphon off the contents of the bowels, but rather allow 
a pint or a quart of the warm saline solution to flush the bowels, and in 
this manner wash away as much of the offending debris as exists within the 
bowels. I have frequently used cold water, but I find much greater benefit 
from the use of a warm solution of the temperature of 105° F. 

Some of our cases require irrigation once in twenty-four hours for one 
week, and others again are so greatly improved after one rectal washing that 
it is not necessary to resort to it again. 



Fig. 71. — Exact Size of Catheter Used for Irrigating a Very Young Infant. 

Starch injections, made by adding 2 tablespoonfuls of the ordinary 
starch to a quart of warm water of a temperature of 105° F., may be gi v en. 
They are very advantageous, as the colon changes starch into dextrin, 
which is easily absorbed. Thus not only does the latter cleanse, but it is 
also nutritious. Large quantities of saline solution can be introduced 
into the circulation by means of colon washing, thus adding, to the volume 
of the blood. I therefore lay great stress on this form of treatment, as 
one of the most valuable for this depleting condition. Thromboses can 
frequently be avoided by these injections. 

When severe tenesmus exists, painting of the lower end of the rectum 
with a 2 per cent, solution of cocaine is frequently very advantageous. Pro- 
lapse of the rectum and anus can frequently be prevented by applying a 
strip of zinc oxide plaster from one buttock tightly to the other, so that the 
buttocks will support the bowel and mechanically prevent its protrusion. 

Summer Diarrhcea. 

In this condition we have a gastro -intestinal disorder due to the toxins 
generated from the bacteria in milk. This usually occurs during the sum- 
mer months, when there is great humidity in the air. The symptoms are 
not so severe as those seen in the acute form of milk infection. It is usually 
met with among the poorer classes, who buy a cheap milk which usually 
contains millions of bacteria. Victor Vaughn, of Ann Arbor, Mich., in a 
letter to me, stated that although it is possible to destroy all bacteria by 
repeated and continued sterilization, he found it impossible to destroy the 
toxins generated in milk even though the temperature was raised to 300° F. 

Cause of Infant Mortality. — The weeds eaten by cows in their summer 
pastures are responsible for many cases of gastro-intestinal disease. Many 



SUMMER DIARRHOEA. 263 

of these weeds are poisonous and their juices pass into the milk. In 
support of this theory Hauser gives the statistics of mortality in a number 
of districts in his experience, classifying them by the soil and the weeds 
that grow by preference on certain soils. 

Bacteriology. — Bacteriological 1 investigation of summer diarrhoea com- 
menced when Escherich, in 1886, published his work on the intestinal 
bacteria of infants and their relation to the physiology of digestion. 
Lesage, Hay em, and Baginsky contributed further researches, but the most 
important and exhaustive researches were made by Booker from 1886 to 
1897. As the result of these he called attention to three principal forms 
of summer diarrhoea, based on a correspondence of their clinical, anatom- 
ical, and bacteriological features: (1) dyspeptic or non-inflammatory diar- 
rhoea, in which the obligatory milk-fseces bacteria are found, chiefly the 
bacillus coli communis, the bacillus lactis aerogenes appearing in smaller 
numbers; (2) streptococcus gastro-enteritis, in which there is a general 
infection and ulceration of the intestine, with streptococci as the pre- 
dominating forms, some bacilli being present as well; (3) bacillary gastro- 
enteritis characterized by a general toxic condition with less intestinal 
inflammation, and the presence in the stool of several varieties of bacilli, 
the proteus vulgaris being the most common. 

Escherich studied the streptococcus cases more closely (1897-1899) 
and found the cocci numerous and in almost pure culture in the stools in 
acute, severe cases, while it was possible to isolate them from the urine 
and the blood during life and from the viscera after death. Clinically, the 
symptoms vary much in the mild and the severe cases; the stools may be 
watery and contain much pus and blood. Staphylococci have also been 
found in diarrhoeal stools, but much less frequently than streptococci. Later 
Escherich described cases of dysentery due to a virulent colon bacillus. 
Valagussa found a bacillus belonging to the colon group and identical with 
that isolated by Celli and Fiocca from cases in Italy and Egypt. In 1898 
Shiga, in Japan, described the bacillus dysenteriae, an organism more nearly 
related to the typhoid than to the colon group, and Flexner found the same 
bacillus in one form of acute dysentery studied in Manila. Both Celli and 
Escherich tried to identify the bacillus they described with that of Shiga. 
The bacillus pyocyaneus has also been found in the stools ' of cases of 
epidemic infantile dysentery. It is evident, then, that no specific bac- 
terium of gastro-enteritis has been found; there is one form in which the 
streptococcus is the predominating organism, and the bacillus dysenteriae 
may possibly be proved to be the cause of epidemic dysentery both in chil- 
dren and in adults. 

Pathology. — Inflammatory lesions and ulcerations can be seen in the 
colon. It is rare to find the duodenum and jejunum involved. The micro- 



ti! editorial in Archives of Pediatrics, August, 1901. 



264 DISEASES OF THE INTESTINES. 

scopical findings of the stool show numerous bacteria, epithelial cells, de- 
tritus, and occasionally blood. Sometimes particles of food are also seen. 

Symptoms. — Vomiting and diarrhcea as in the acute form are the main 
symptoms. If an infant has just recovered from an acute milk infection 
and is placed on milk feeding too soon, a relapse frequently occurs, which 
is a subacute infection. The stools are greenish and resemble those de- 
scribed in the acute form. There is a loss of appetite, a coated tongue, and 
the temperature ranges between 101° and 105° F. ; at times the tempera- 
ture may be normal or subnormal. The infant does not want to be dis- 
turbed, and is very irritable. The irritation and tenesmus accompanying 
this diarrhcea usually cause the rectum to prolapse, and from the constant 
discharges of the bowel the anus and buttocks are excoriated. An eczem- 
atous eruption frequently is seen between the thighs. Local infection of 
the skin and lymphatics, by the presence of the pyogenic bacteria, some- 
times causes furuncles. 

Diagnosis. — This is usually made when the history and symptoms are 
carefully noted. It is much milder than cholera infantum. The tempera- 
ture is lower, the vomiting less, and the prostration not so marked. 

Jonah W., seven months old, twin baby, bottle-fed, had been constipated since 
birth. There was a slight cough. The child had beaded ribs, craniotabes, and bald- 
ness of the occiput. Since one month he had vomiting and diarrhoea. This had 
improved and disappeared entirely. The child was given milk, and ten days after 
the milk diet was commenced the symptoms of vomiting and diarrhoea again appeared, 
but in a milder form. Several furuncles were found on his scalp. Owing to the 
intolerance of milk, whey was given in the same quantity and frequency as the milk 
was formerly given. Rice water, barley water, and thickened pea soup were allowed. 
Toast water was given fo* thirst. Cocoa was also given without milk. The cocoa 
was made with rice water, in the following proportions: — 

I£ Cocoa 1 drachm 

Rice water 8 ounces 

Saccharine *4 grain 

Scald about five minutes. 

A large dose of castor oil followed by a 2-grain dose of tannopine every two 
hours was given. A high saline injection, 1 quart, temperature 115° F., was ordered 
to cleanse the rectum and colon ; also for its stimulating effect. 

The diagnosis of subacute milk infection, congenital syphilis, and furunculosis 
was made. The case recovered. 

Prognosis and Complications. — This depends on the condition of the 
child. If there is a complication such as nephritis present, then the prog- 
nosis is worse than if uncomplicated. If an infant can be removed to the 
seashore from unsanitary surroundings and proper food given, the prog- 
nosis is good. 

Treatment. — Two points to be considered in this condition are : First, 
stop all milk for at least one week and give the stomach and bowels absolute 



SUMMER DIARRHCEA. 265 

rest. Second, cleanse the stomach and bowels of all offending debris which 
may have caused this trouble. Such cases should be put on a light, nutri- 
tious diet. 

The golden rule is to give the stomach and bowels absolute rest in both 
quality and quantity of food. The feeding interval should be longer and 
the amount of food reduced. 

In substituting other forms of feeding, pro tempore, we invariably do 
so at the expense of body weight. It will always be noted that children 
deprived of milk will lose weight unless care is taken to substitute a proper 
nutritious food. The body will lose to such an extent that atrophy may 
frequently follow. 

Formula for Weak Infants in Substitute Feeding. — When vomiting and diar- 
rhoea persist give either: — 

Barley water 4 ounces 

Rice water ....." 4 ounces 

Oatmeal water 4 ounces 

Or: — 

Whey 4 ounces 

Feed every two or three hours. Add % of yolk of egg to each feeding. 

If fermentation exists — colic, greenish stools, and eructations — use 
saccharine, % grain, instead of sugar for sweetening. 

The liquid culture of the Bulgarian bacillus generates lactic acid. This 
liquid culture has served me very well in acute enterocolitis, and especially 
to control fermentation and colic caused by intestinal toxic bacteria. The 
liquid culture in drachm doses, repeated every three or four hours, is non- 
toxic. Older children may also .have junket, cream cheese, albumin-water 
and expressed beef-juice. 

Medicinal Treatment. — A dose of castor-oil should be given at the 
beginning of the treatment, first to cleanse the gastro-intestinal tract, and 
secondly, for its constipating after-effect. Ehubarb and soda mixture in 
doses of one-half teaspoonf ul is valuable after the castor-oil has been given. 
The treatment described in the article on "Intoxication" should be 
carried out as well in- this condition. The successful outcome of the 
case depends on proper rest, careful stimulation, and a thorough cleansing, 
aided by a decided change of air, to the seashore or to the mountains. Milk 
should not be given until all conditions appear normal. Essence of caroid 
in teaspoonful doses, every three hours, is serviceable. Powdered caroid 
combined with charcoal, in doses of 3 grains each, repeated several times a 
day, is very valuable. 

Carbolic acid is extolled by some physicians with large experience in 
infantile diseases. S. Henry Dessau strongly advises a 1 per cent, solution 
of carbolic acid as an intestinal corrective when fermentation exists. He 
has not seen any toxic symptoms from its use. I can fully indorse his 



266 DISEASES OF THE INTESTINES. 

statement and usually advise watching the urine during the administration 
of carbolized water. A teaspoonful of a 1 per cent, solution, sweetened 
with saccharine, can be given three or more times a day. If no effect is 
noticed in twenty-four hours, then iy 2 or 2 teaspoonfuls can be given at 
each dose. I have also used creosote water, 1 per cent, solution/ in the same 
doses as carbolized water with- excellent results. 1 

Constipation and Chronic Constipation. 

The bowels of an infant during the nursing period should have one 
or two evacuations daily. Some children will be quite normal with 
one evacuation daily. Older children who partake of solid food suffer 
more frequently with constipation. There are decided peculiarities noted 
in children with reference to the movements of the bowels. One child 
will enjoy good health, have a good appetite, and will gain in weight with 
three or four movements of the bowels daily. Another child in equally 
good health will have but one movement daily. These differences or 
peculiarities must be taken into consideration before definitely maintain- 
ing that our patient is really constipated. 

The colon ascendens being very short, the surplus of length, partic- 
ularly as the transverse colon also is not long, belongs to the descending 
colon, and especially to the sigmoid flexure. Drandt found it between 8 
and 24 centimeters in length, averaging from 14 to 20 centimeters. Jacobi 
saw a case in which it was 30 centimeters long. 

As the pelvis is very narrow, the great length of the lower part of the 
large intestine is the cause of multiple flexures, instead of the single sig- 
moid flexure of the adult. Thus it is. that, now and then, two or even 
three flexures are found, and to such an extent that one of them may be 
found to extend as far as the right side of the pelvis. Cruveilhier and 
Sappey speak of this position of the lower part of the intestine in the 
right side of the pelvis as an anomaly. Huguier finds it on the right side 
of the body in the majority of cases. Others only occasionally, although 
they admit the great length of the sigmoid flexure. In common with 
Huguier, who even proposes to operate for artificial anus in the right side, 
Jacobi found one of the flexures on the right side many times. 

The great length of the large intestine and the multiplicity of its 
flexures are of great functional importance. At all events, they retard the 
movement of the intestinal content, facilitate the absorption of fluids, and 
thus the fasces are rendered solid. When this length is developed to an 
unusual extent, constipation is the natural result. 

Eecords of post-mortem observations made by Dr. T. C. Martin 2 prove 



1 See chapter on "Decomposition" for general treatment of Summer Diarrhoea. 

2 "A Study of the Difficulties of Defecation in Infants," by Dr. T. C. Martin, 
read at the forty-eighth annual meeting of the American Medical Association, June 
4, 1897. 



CONSTIPATION. 



267 





Fig. 72. — Ascending Position. 



Fig. 73. — Ascending Position. 





Fig. 74. — Transverse Position. 



Fig. 75. — Transverse Position. 





/ 



Fig. 76. — Descending Position. 



Fig. 77. — Descending Position. 



Illustrations of the various types of abnormality of the sigmoid 
flexure, which are the source of habitual constipation in infants. (After 
Marfan and Neter.) 



268 DISEASES OF THE INTESTINES. 

that the muscular development of the adult rectum and lower sigmoid is 
plainly apparent, and that a deficient muscularity is observable in the in- 
fant specimens. In the infant gut the intrinsic power of peristalsis is not 
present in that degree necessary to it as a competent expulsory factor. 

The meso-peritoneum of these parts in the adult is, , relatively, very 
considerably shorter than that in the infant. The adult gut is slightly 
tortuous; that of the infant is much angulated. Mobility and angulation 
of the infant gut conspire to obstruct the passage of formed faeces. 

The rectal valve appears to bear the same proportion to the gut in both 
adult and infant, but when the difference in muscular development in the 
two is noticed the disproportionate great resistance of the valve in the 
infant rectum becomes an obvious fact. 

Causes. — This condition is most frequently met with in bottle-fed 
infants. It is sometimes caused by a deficiency in the amount of sugar, or a 
deficiency in the amount of fat in the infant's food. An insufficient quan- 
tity of water in the diet is sometimes responsible. 

In dyspeptic or rachitic infants the peptic and intestinal glands do not 
perform their normal functions; this absence of intestinal glandular secre- 
tions is one of the main factors in the causation of this condition. In- 
complete peristalsis, such as exists in the rachitic debility of the muscular 
layer, in the muscular debility dependent upon sedentary habits and peri- 
tonitis, intestinal atrophy, and hydrocephalus, results in constipation. Boil- 
ing or sterilizing the milk fed to infants renders it constipating. 

Symptoms. — Some children are in apparent health; others show con- 
stant crying, with the legs drawn up; flatulence and a distended abdomen 
are the symptoms most frequently noted. A temperature of 102° to 104° 
may sometimes be caused by the stagnation of faecal matter in the intestinal 
tract. Loss of appetite, restlessness at night, may frequently be noted in 
such infants. In older children anorexia, headache, and stomachache will be 
described. Eructations and flatulence usually accompany constipation. 

Diagnosis. — Before the diagnosis of constipation is made, we must be 
sure to exclude pyloric stenosis, intestinal obstruction, or incarcerated her- 
nia as a possible cause of this condition. In like manner cystic tumors in 
the intestine may give rise to symptoms of constipation. We must also 
exclude the possibility of our dealing with a case of Hirschsprung's disease. 

The diagnosis should not be made without bimanual examination. In 
most of the cases the abdomen is inflated, though it be painless. The 
faeces come away in small, hard lumps or in large masses. The liver and 
spleen are displaced. The liver may be so turned that a part of its posterior 
surface comes forward. The abdominal veins are enlarged to such an 
extent that they form circles around the umbilicus, similar to what is seen 
in hepatic cirrhosis. These children lose their appetite, sometimes vomit, 
and the irritation produced by the hardened masses in the intestinal canal 



CONSTIPATION. 269 

may be such as to finally result in diarrhoea, which, however, is not always 
sufficient to empty the tract. 

There is, besides, an apparent constipation, which should not be mis- 
taken for any of the above varieties. Now and then a child will appear to 
be constipated, have a movement every two or three days, and at the same 
time the amount of faeces discharged is very small. This apparent con- 
stipation is seen in very young infants rather than in those of more ad- 
vanced age. Such children are emaciated, sometimes atrophic. They ap- 
pear to be constipated because of lack of food, and not infrequently this 
apparent constipation is relieved by a sufficient amount of nourishment. 

Treatment. — Our aim should be to modify the food, if the same is at 
fault. It must be remembered, however, that many factors may induce 
coprostasis ; for example, deficiency in the tone of the intestinal muscles and 
insufficient peristaltic wave's result in the stagnation of the intestinal con- 




Fig. 78. — Rubber Bulb Syringe. 

tents. Deficient secretions of the intestinal glands favor constipation, so 
also a deficient secretion of bile. 

The indications for the treatment of a given case of constipation de- 
pend upon the cause which leads thereto. If an atony of the gastrointes- 
tinal tract with deficient peristalsis exists, then stimulation by means of 
massage should be carried out. In addition thereto nux vomica in the 
form of tincture should be' given in 1- or 2- drop doses three times a 
day. 

For the immediate relief of constipation in an infant a glycerine or 
gluten suppository should be used. If this is not effectual, an injection of 
y 2 pint castile-soap water should be given. When constipation per- 
sists, it may be necessary to give a soap-water injection every evening for 
many weeks. There is no danger in this procedure even though it be con- 
tinued for several months. 

When hard, dry, scybalous masses are passed and the infant strains 
considerably, it is advisable to inject 2 ounces of lukewarm sweet oil, with 
a small syringe, before the infant retires. If the buttocks are supported 
for several minutes after such injection, we favor the retention of the oil. 
Such oil injections will soften the hardened masses and favor their expul- 
sion the following morning. 

If constipation cannot be relieved by the simple methods above pro- 



270 



DISEASES OF THE INTESTINES. 



posed, it may be necessary to use a catheter inserted between six and 
eight inches into the colon. If we inject about 8 ounces of warm 
water and % teaspoonful of the inspissated ox-gall into the colon, we 
will have excellent results. Owing, to the irritating nature of the ox-gall, its 
use should be restricted to fever, or when the child is very ill, and we aim 
at a rapid evacuation of the colon and rectum. 

Drug Treatment. — No one should expect to cure a constipation by the 
use of drugs alone. There are so many factors which must be considered 
that drugs form but one part of the treatment. 




Fig. 79. — Irrigator, with Tube Attached and Hard-rubber Points. 

For older children, a teaspoonful of maltine with cascara sagrada taken 
in the morning, once only, is an excellent laxative. When a large quantity 
of starchy food is fed, resulting in an excess of acid, calcined magnesia 
should be given. In rachitic and general atonic conditions % to 1 tea- 
spoonful of olive-oil or codliver-oil may be ordered three times a day, 
or aromatic albolene, 1 teaspoonful in the morning as a laxative. 

Dietetic Treatment.— -For a very young infant, y 2 teaspoonful of 
malt extract, or 1 teaspoonful of Loefflund's malt soup, may be added 
to each feeding. In estimating the required dose of malt soup it is impor- 
tant to supervise daily the frequency and character of the movements. 
Individual peculiarities must be considered. One infant will have an ex- 
cellent result from 1 teaspoonful added to the morning feeding, whereas 
other infants will require the same dose added to every feeding. Milk of 



CONSTIPATION. 271 

magnesia, 1 teaspoonful given in the morning, to bottle-fed infants, dur- 
ing the first half-3 T ear, is an excellent corrective. The method of heating 
the food, the source of the milk supply, and the quantity of water given 
the infant are all factors to be considered when dealing with an infant suf- 
fering from constipation. Instead of using plain water as a diluent of the 
food, use oatmeal water, if constipation persists. Sometimes diluting the 
milk with a 5 per cent, solution of sugar of milk will relieve this condition. 

For infants over 1 year a small saucer of oatmeal porridge containing 
a drachm of butter may be tried. A teaspoonful of sugar of milk may be 
added to one feeding. 

It must be remembered that bread, potato, macaroni, and most of the 
carbohydrate foods have a tendency to constipate. Prunes and senna leaves 
stewed to a jelly in sugar and water, apple sauce, oranges, grapes, and grape 
jelly all have a laxative tendency. When the casein of milk is altered by the 
Bulgarian bacillus into a casein lactate it has a laxative tendency. All 




Fig. 80. — Soft-rubber Rectal Tube for Irrigating the Colon. 

fermented milks and buttermilks loosen the bowels. One or 2 ounces 
of fermented milks may be given ; large quantities produce colic. 

Exercise. — What massage is for a young infant, exercise is for an older 
child. Thus, it is apparent that atonic conditions can best be relieved by 
combating the dietetic and medicinal treatment with out-of-door exercise. 
Children should be permitted to romp about and walk and play out of doors, 
but not to a point approaching fatigue. Older children will find bicycle 
exercise or horseback riding decidedly beneficial. It is important, however, 
to regulate the amount of such exercise, and thus it is the physician's duty 
to tell the mother or nurse just how long a child should be permitted to 
exercise. It would seem that one-half hour twice a day is ample to arrive 
at beneficial results. Overindulgence in such sports will frequently result in 
rupture and produce heart strain. In cardiac lesions, in asthmatic condi- 
tions, if children suffer with whooping-cough, and in tuberculous conditions, 
such exercises must not be allowed. 

Massage. — Continued kneading of the abdomen with the aid of vase- 
line or oil will be found serviceable, and, if properly done, will provoke an 
action of the bowel. Thus it is that rubbing the abdomen with castor-oil 
has frequently been recommended in the treatment of constipation; the 



272 DISEASES OF THE INTESTINES. 

effect supposed to be due to the castor-oil is, in reality, due to the massage, 
and to nothing else. When vibratory massage is used, it should be con- 
tinued from five to ten minutes every day for one month. ■ This will cer- 
tainly aid and stimulate peristalsis, and ultimately tone the muscles and 
cure the constipation. 

The hands are gently placed on the right side of the abdomen at about 
the ileo-cascal region. Gentle pressure should be made; otherwise, the 
abdominal muscles will be tense. Commence each stroke of the massage 
with gentle pressure and utilize each inspiration for firmer and firmer 
pressure. The same method of palpation which is employed for the 
diagnosis of a tumor in the deep tissues should be employed. After firm 
pressure has been made, we can then gradually massage by a rotary move- 
ment, first, the ascending colon, continue over the transverse colon, and 
finally over the descending colon and rectum. Hardened scybala can fre- 
quently be felt in the region of the caecum and can be propelled by this 
mechanical treatment through the various portions of the colon to the 
rectum. 

Massage from five to ten minutes morning and evening may be con- 
tinued several weeks. If improvement is noted, then less frequent treatment 
is required. To be successful, several months of treatment may be neces- 
sary in obstinate cases. We must persist in stimulating the peristaltic 
waves regularly and not be disappointed if immediate results are not 
secured. My plan has always been to inform the parents that I do not 
expect any success in a chronic constipation which has persisted for months 
or years, until six months or more have passed. 

Electricity. — This is very valuable to stimulate peristalsis. The 
faradic, galvanic, or static current can be used. For the general practi- 
tioner the use of the galvanic current, five to ten cells, is sufficient. The 
negative pole (cathode) should be applied in the rectum, and the positive 
pole, which produces peristaltic waves, should be applied over the ascend- 
ing, descending, and transverse colon. Local contractions result from the 
negative pole. A gentle faradic current applied over the spine and the 
abdomen will answer if used for several minutes in the absence of the 
galvanic current. Galvanic electricity should be used every day; fre- 
quently months are required to insure a cure, in conjunction with the 
medicinal and dietetic treatment. 



Hirschsprung's Disease (Dilatation of the Colon; Megacolon). 

Dilatation of the colon and hypertrophy of the colon may be due to 
muscular weakness or a partial defect in the muscles of the lower portion 
of the large intestine. When such condition exists there is a stagnation of 
faecal matter, and we have the usual products of fermentation and decom- 



INTESTINAL COLIC. 273 

position. The latter will give rise to considerable flatulence and by reason 
of the muscular weakness of the intestinal walls there results a dilatation 
which remains permanent. 

There are two prominent symptoms characteristic of this disease : first, 
obstinate constipation, in some cases extending over many days; second, 
extreme abdominal distention. 

Some of these cases by reason of the stagnation of faecal matter will 
- show loss of appetite, marked irritability, and insomnia. The urine usually 
contains indican. 

The diagnosis depends on whether or not the condition can be traced 
back to early infancy. It is important to differentiate this disease from 
ovarian tumor, cirrhosis of the liver, or abdominal cysts. The diagnosis 
may be grave if colitis ends in an ulcerative process. 

The treatment consists in abdominal massage and mild, stimulating 
laxatives. It is important to correct the stagnation of faecal matter by 
daily injections of soap water. Surgical aid, such as resection of the intes- 
tine, may be demanded in the severer forms of the disease. An artificial 
anus has been suggested; this must be considered, however, as a temporary 
benefit only. 

Intestinal Colic (Intestinal Neuralgia; Enteralgia). 

Intestinal colic consists of pain which is paroxysmal in character, 
located in the bowel, and without evidence of inflammation. 

Symptoms. — Colic is one of the most frequent causes of crying in 
children. They not only cry loudly, but will suddenly shriek, and when 
put to sleep will awaken with a sudden start, and cry loudly. The legs are 
usually flexed or they will move their legs back and forth, or up and down. 
They will seem to bend the body on itself. These attacks are usually asso- 
ciated with constipation; hence, it is a good plan, when the child is rest- 
less and utters a painful cry, to see if the bowels have moved. It is well 
known that this colic may be as well associated with diarrhoea. The origin 
of all colic is certainly the feeding. When dyspeptic conditions, arising 
from undigested particles of food in the bowel, .exist, then fermentation, 
resulting in gas formation, is the result. 

Colic is frequently, but incorrectly, known by the terms of "meteoris- 
mus" or "tympanites," but in the latter conditions the abdomen is greatly 
distended, and there is a permanent enlargement of it. Borborygmus 
(rumbling sounds) can usually be made out, if the ear is applied to the 
abdomen. The vast majority of cases of colic have their seat in the 
intestine, and can be relieved very quickly. 

Causes. — Worms (ascarides) have been known to cause colic. When 
there is a general loss of tone on the part of the muscular layers in the walls 
of the intestine, colic will frequently result. Jacobi believes that colic can 

18 



274 DISEASES OF THE INTESTINES. 

be caused by chronic peritonitis resulting in adhesions or local changes in 
the walls of the intestine that will produce- local contractions or dilatations. 
Excess of Sugar. — When colic is caused by an excess of sugar, there 
will be considerable eructations of gas, and, frequently, small quantities of 
food will be regurgitated. 

The stools, when an excess of sugar is given, are thin and greenish, 
smell very acid, and usually produce a reddened excoriation of the buttocks 
around the anus. 

When children show a tendency to the development of gas and have 
constant recurring colic, my plan is to discontinue the use of sugar until 
such time as this fermentation is absent. To sweeten the food I use small 
saccharine tablets, 1 grain being ample to sweeten 1 pint of food. When 
there is a tendency to constipation, it is possible not only to sweeten the 
food, but also to modify this constipation by adding a teaspoonful of malt- 
extract to each bottle. One-half teaspoonful of calcined magnesia added to 
each bottle of food will also relieve constipation. 

Excess of Protein. — A careful observation of the stools would easily 
show whether the albuminoids are in excess, for they are usually present 
in the form of curds. This condition is usually associated with constipa- 
tion, and the indication would be to cut down the quantity of protein 
administered. 

Undigested curds due to excess of protein and excessive fats are a 
frequent cause of colic. Irregular feeding, too frequent or over-feeding, 
are the commoner causes. The majority of cases of colic are seen in bottle- 
fed babies. This is usually due to milk which is too acid or superheated 
milk, as in prolonged sterilization. In the latter manner of treating milk 
the casein is rendered very difficult to digest, and frequently results in 
intestinal fermentation, causing colic. 

Colic in Breast-fed Babies. — If colostrum continues and the milk does 
not assume normal conditions, colic may result. Colic is frequently seen 
during menstruation of nursing women. Pregnancy occurring during lac- 
tation usually causes colic. 

Differential Diagnosis. — We must be extremely careful to exclude the 
pain of intussusception, the pain from gall-stones, the pain of appendicitis, 
or the pain of a strangulated hernia. The absence of fever, the disappear- 
ance of the symptoms by the regulation of the diet, the flushing of the 
colon to remove the offending cheesy debris, will materially aid in strength- 
ening the diagnosis. Sudden cry frequently denotes earache. In infants 
the ears should be examined in all febrile conditions. 

Infant J., eleven months old, bottle-fed, cried and suffered with pain from 
one to two hours after taking his feeding. The temperature was 101° F., rarely 
higher. The infant would scream for a few minutes at a time, then expel flatus per 
rectum, and be apparently relieved. He would be cheerful and play for a short 
time, when another paroxysm of pain would come on and start him screaming again, 



INTESTINAL COLIC. 275 

until flatus was expelled. Relief was immediately given when the rectum and 
colon were flushed with warm water temperature 105° F. to which several ounces 
of glycerine had been added. Antifermentatives, such as rhubarb and soda mixture, 
or several grains of calcined magnesia, invariably relieved the child and prevented 
intestinal fermentation. 

The treatment of colic is simple when the cause is known. The quick- 
est method of relieving colic is to give an enema of soap and water or of 
warm chamomile tea. Take an ounce of German chamomile flowers 
and steep them in a quart of boiling water from ten to fifteen minutes, 
then strain. With the aid of a rectal tube allow 1 or 2 pints of 
chamomile tea at a temperature of 100° to 110° F. (no hotter) to flow 
slowly into the rectum and the colon. When the colon is thoroughly flushed 
with this warm tea, and emptied of its faeces, it is usual for the attack of 
colic to cease. In addition to washing the colon, it is a good plan to apply 
a small bag of either chamomile flowers or slippery elm bark, or ground 
flaxseed meal. To do this, I make a bag of cheese-cloth capable of holding 
from 1 to 2 ounces, and then fill it with one of the above-mentioned ingre- 
dients; sew the bag shut when filled, and heat it before applying to the 
abdomen. Several of these bags can be made and kept in readiness, so that 
they can be applied quickly. It is a good plan to have one heating on the 
stove while another is on the abdomen. These little bags are very soothing. 

Massage. — During an attack of colic gentle massage with warm sweet- 
oil or melted vaseline or lard will be very comforting to the child. The 
distended abdomen should then be thoroughly massaged until the gas is 
expelled and the warm applications applied. 

Drug Treatment. — If the colic originated from a fermentative dys- 
pepsia, then treatment must be directed to the stomach. For this purpose 
antifermentatives, like the mistura rhei et sodas, should be given in doses of 
% to 1 teaspoonful, diluted with water, every two or three hours until there 
is a thorough evacuation. Five to 10 grains of bismuth or i/^-grain doses 
of resorcin will also be found useful. Paregoric in doses of 10 to 15 drops 
should be administered to children of six months or older. It is under- 
stood that no physician will forget the danger of giving repeated doses of 
paregoric or permitting the same to be administered by incompetent persons 
not aware of the dangers of the drug habit. The author has not only seen 
distinct opium poisoning follow the use of paregoric, but has also had occa- 
sion to see the distinct opium habit in very young children. This was 
reported by me in a paper read before the New York County Medical 
Society, January 22, 1894. 1 For an infant during the first few months, it 
is hardly safe to give more than 5 drops of paregoric, repeated in an hour 
if there is no relief. Another drug that has served me very well is Hoff- 
mann's anodyne in doses of from 1 to 5 drops, repeated in an hour if 

1 Published in extenso in the Medical Record of February 17, 1894. 



276 DISEASES OF THE INTESTINES. 

necessary. For an infant up to two months, 1 drop per dose; from two to 
four months,- 2- drops per dose; four to six months, 3 drops; six to nine 
months and until 1 year of age, 4 drops; children from 1 to 2 years, 5 
drops.- This is to be given in a teaspoonful of sterilized water. Another 
valuable drug, and one that is to be given cautiously, and in the same 
doses as Hoffmann's anodyne, is spirits of chloroform; never should more 
than from 1 to 4 drops be given to a child up to 1 year of age, and younger 
children less in proportion. I cannot favor the administration of nauseating 
or foul-smelling drugs, such as asafcetida. We must try to cater to an 
infant's taste, especially so when in pain. 

An excellent preparation to relieve colic is calcined magnesia, or milk 
of magnesia, made by Phillips. 1 It has served the writer very well, espe- 
cially in young infants, where acidity was prevalent. A half-teaspoon- 
ful several times a day was enough in some cases, while others required 
several teaspoonfuls during the day. It is valuable where constipation 
exists, and can be added to the bottle of food. 

Chronic Intestinal Indigestion (Duodenal Catarrh; 
Mucus Disease) . 

This condition is always associated with a chronic derangement of the 
stomach. It is usually a functional disturbance and is one of the most 
difficult conditions to treat in children. 

Etiology. — This is usually obscure, although it follows exhaustive dis- 
eases such as typhoid, diphtheria, or other infectious diseases. The most 
frequent cause is improper food, unsuited for the age and development of 
the child. 

Symptoms. — As a rule, gastro-enteritis precedes this condition for 
months, in each and every case. The stool shows a tendency to looseness 
and mucus is found covering the fasces. The mucus is seen in shreds and 
masses at times covering the faecal matter. Such children are usually 
backward in development. They are very irritable, tire easily, and lose 
in weight. 

As a rule, the abdomen is distended. There is no fever. The appetite 
varies and is poor. The liver does not functionate properly, and in some 
cases very little bile is secreted, giving rise to clay-colored stools. The skin 
is dry. 



1 Phillips's Milk of Magnesia — Eydrated Oxide of Magnesium (MgH 2 2 ). — A 
teaspoonful of Phillips's Milk of Magnesia is equivalent in acid-neutralizing power 
to 4 ounces of lime water, or 10 grains of sodium bicarbonate. It will neutralize 
nearly twice its volume of lemon juice. Each fluidounce represents 24 grains of 
magnesium hydrate. Dose: From a teaspoonful to a tablespoonful, according to 
age — increased or diminished at discretion. Dilute with equal quantity or more of 
water. 



CHRONIC INTESTINAL INDIGESTION. 27? 

Diagnosis. — The only condition which might resemble chronic intes- 
tinal indigestion is general tuberculosis. The absence of cough, the ab- 
sence of fever, and the absence of physical signs in the lungs should help 
to exclude tuberculosis. The diagnosis will be more readily made when 
previous gastric or gastro-intestinal derangements are taken into account. 

Prognosis. — This is usually good, even though these attacks may ex- 
tend over } T ears. If, however, rapid emaciation and general weakening of 
the heart exists, the prognosis becomes grave. 

Treatment. — Dietetic Treatment: This is the most important part 
of the treatment and requires very careful consideration. Excessive fats 
and sugars should be avoided. Light meals rather than heavy should 
be ordered. Give predigested food if required. Whey, skimmed milk, 
zoolak, thin cocoa, chicken broth, beef broth, clam broth, soft-boiled egg, 
fish, oysters, raw scraped steak, apple sauce, baked apple, to be varied with 
other well-stewed fruit, should be given. Avoid all fresh bread. Busk 
(zwieback) may be given. Give all green vegetables in season. Avoid all 
heavy cakes, pies, and puddings. If this light diet is continued for several 
months great improvement will be noted. The ultimate care will depend 
on restricting the diet to nutritious and very easily digested food. 

Medicinal Treatment.— Give nux vomica, 1 to 3 drops, three times a 
day, before meals. Or : — ■ 

Ifc Acid, hydrochlor. dilut 1 ounce 

Five minims three times a day, after meals. 

Pay careful attention to the bowels; give a laxative if necessary. If 
severe anaemia exists then give : — 

1$ Tr. ferri acet. seth - 1 ounce 

Ten drops, three times a day. One hour after meals. 

This has been found to be the best form of iron in the management of 
this condition. 

A girl, 8 years old, was breast-fed in infancy and appeared apparently healthy. 
Her dentition, walking, and talking normally developed about the end of the first 
year. During the second year she suffered with measles. When 4 years old she 
had an attack of acute milk poisoning, resulting in gastro-enteritis. From this 
time on she has not been in good health. She complained of headaches, nausea, 
and anorexia. She has a foul breath, and is very anaemic. She does not seem to 
thrive. The slightest imprudence in eating causes gastric symptoms. Her abdomen 
is large and gas is frequently expelled per rectum. She is always languid. The 
temperature is normal, the pulse-rate feeble; it usually ranges between 90 and 
100. She does not sleep well, talks in her sleep and tosses about. Under a rigid 
diet, excluding pure milk, and giving diluted milk, whey, thin soups, soft-boiled eggs, 
and fruit, improvement was noted. The interval of feeding was restricted to five 
hours, so that the child was fed three times a day. A daily movement of the bowels 
was insisted upon. One-half teaspoonful of phosphate of soda in a teacup of warm 
water was given when the child was constipated. Five drops of acid hydrochloric 



278 DISEASES OF THE INTESTINES. 

dilute was given three times a day. The case improved and the child is in a good 
condition to-day. 

Appendicitis. 

Appendicitis is an inflammatory condition in and about the vermiform 
appendix. The size of the appendix varies in infancy. Eibbert gives 3.4 
centimeters as the average length, whereas Tojts found the average length 
to be 5 centimeters. A characteristic of the appendix in infancy is the 
general richness in follicles. Fsecal concretions are rarely found in the 
appendix of infants and young children; this may be due to the fluid diet. 
The appendix usually contained parasitic ovi and mucus, besides undigested 
particles of food. 

Position of Appendix in Infancy. — The appendix is situated higher 
than McBurney's point. No definite rule applies to the position during 
infancy. It may be found pointing downward into the pelvis, or it may 
be directly on the cecum in the right iliac fossa, or it may point upward. 
Cumston reports a case in which the tip reached the right lobe of the liver. 
The appendix has an anatomical similarity with the tonsils. Both are 
composed of lymphatic tissue, and are adjacent to cavities filled with 
bacteria. The appendix partakes of the inflammatory process of the struc- 
ture with which it is intimately associated. 

Bacteriology.— Macaigne and Cumston found that cultures of the bac- 
terium coli obtained from stools of patients suffering with appendicitis were 
far more virulent than similar cultures from healthy subjects. The strep- 
tococcus in milder cases produces a serious catarrhal process., The bacillus 
coli is the commonest organism found in appendicitis, although the strepto- 
coccus is frequently associated with it. 

Klecki 1 found that pathogenic bacteria of a most virulent type can 
penetrate the peritoneal cavity. This penetration is either during perfora- 
tion or through the lymph spaces of the damaged intestinal walls. The 
bacteria penetrating into the mucosa and muscularis may produce rapid 
necrosis of the tissue elements, the occurrence of perforation depending 
upon the virulence of the organism present and to some extent the position 
of the appendix in which gangrene occurs. In infants and very young 
children inflammatory processes in the appendix tend to progress rapidly, 
that is to say, necrosis of the mucosa and muscularis occurs promptly, so 
that the bacteria reach the serosa quickly before protecting adhesions have 
had time to be thrown off. For this reason it was found that in 50 per 
cent, of cases of appendicitis in infants and young children extensive peri- 
tonitis developed, this being based on the combined statistics of Schule, 
Rotter, Lenander, and Sonnenburg. 

Death is frequently caused by the toxic forms of appendicitis. The 



x Annales de I'Institut Pasteur, vol. lix, p. 710. 



APPENDICITIS. 279 

absorption of the bacterial toxins causes the body to be overwhelmed with 
this poison. A thrombophlebitis of the vessels of the mucosa takes place; 
the bacteria become attached to the thrombi, liquefy them, and thus enter 
into the general circulation, producing metastatic foci in distinct organs, 
such as the lung, kidney, and myocardium. Thick, inflammatory adhesions 
always denote a previous inflammatory process. In 1867 Willard Parker, 
in the Medical Record, stated that necrosis with rapid perforation of the 
appendix was quite frequently found in children. 

Pathology. — Catarrhal Appendicitis: In this form the walls of the 
appendix are found thickened and hyperasmic. The lumen of the tube is 
filled with debris of inflammation. If this inflamed condition continues, 
the canal may become obliterated. The catarrhal stage frequently ends in 
resolution. 

Ulcerative Appendicitis. — In this condition the process involves the 
muscular coat, because the mucous and submucous tissues have been de- 
stroyed. The ulcer frequently terminates in perforation. 

Gangrenous Appendicitis. — In this condition, also known as intestinal 
appendicitis, rapid necrosis of all the coats of the intestine takes place. If 
a faecal concretion exists and the ulcer perforates, an infection of the peri- 
toneal cavity takes place from the virulent bacteria. This is usually due to 
a thrombosis of the artery of the appendix by direct extension of the in- 
flammatory process in the intestine. By this means the entire nutritive 
supply to the organ is shut off and a rapidly progressing partial or total 
necrosis results. 

Suppuration frequently follows the serous exudation, and a localized 
abscess is formed. The danger of such an abscess consists in the perforation 
taking place and the escape of the pus into the peritoneal cavhVy, setting up 
a diffuse peritonitis. 

Causes. — Injury to this region, exposure to extreme cold, and overin- 
dulgence in purgatives have been looked upon as causative factors. Whether 
foreign bodies, such as seeds or hair swallowed by mouth, will lodge in the 
appendix and cause this disease is doubted by many. 

Cases of helminthic appendicitis have been reported in which 
oxyurides were found in the tip of the appendix. Pfoundler and Schlossman 
report a case in which a larger number of ascarides were found. 

Symptoms and Diagnosis. — Muscular rigidity cannot be depended upon 
as a symptom in children. Every young child resists an attempt to examine 
the abdomen. Cutaneous hyperesthesia is often significant of appendicular 
inflammation. A sharp pain is elicited when the skin is lightly touched. 

Palpation of the appendix is always somewhat problematical. We may 
be deceived by loops of the intestine in that region, or by the psoas muscle. 
If the appendix is very superficial, and if it is distended by an empyema, 
then only can a positive diagnosis be made. 



#80 DISEASES OF THE INTESTINES. 

Pain in the right iliac fossa is rarely a prominent symptom in children. 
Some children complain of an acute pain, neuralgic in character, in the 
right thigh. An abscess may appear in the left iliac fossa or in both 
f ossse at the same time ; the so-called left-sided appendicitis is a left iliac 



Subjective symptoms in children must always be carefully interpreted ; 
fear will frequently prevent complaining when an operation or a hospital 
has been spoken of. Localized abscess is not ■ as frequent as a general 
peritonitis, nor can we make out a tumor as promptly in children as in 
adults. 

Tense abdominal walls with distention more marked on the right side 
would lead us to suspect an inflammation in and around the appendix. The 
csecal region can be easily palpated in a child. If it is impossible to properly 
examine the abdomen and rectum, then an anaesthetic should be given and 
a proper examination made. 

Eectal examination is advisable in every case where an appendicitis is 
suspected, and where vomiting and diarrhoea are marked. Palpable resist- 
ance may sometimes be made out in the right pelvis. If pus has formed, 
a tumor surrounding the rectum can be felt. The temperature may rise as 
high as 105° in some cases and remain as low as 101° in other cases. It is 
only at the beginning of an acute inflammatory appendicitis that we will 
have a rise in temperature. Septic cases will frequently show a normal 
temperature; therefore, the temperature must not be our guide as to the 
necessity for an operation. The pulse is a more positive guide as to the 
presence of an inflammatory process; it also offers a distinct indication for 
an operation. A septic appendix will show its presence by an increased 
pulse; thus, the pulse rate in an acute attack may vary between 90 and 100, 
but if resistance is poor the pulse rate may rise to 110, 120, or 130 beats 
per minute, and the prognosis is correspondingly bad in such a case. 

Vomiting is an early symptom and one that occasions considerable dis- 
comfort. In mild forms of the disease vomiting generally subsides. When 
peritonitis complicates, vomiting usually recurs. Periodical attacks of 
vomiting, so-called cyclic vomiting, may be a symptom of chronic appendi- 
citis, with interval attacks. 

The Bowels. — It is difficult to say whether constipation or diarrhoea 
more often accompanies these attacks. I have seen cases in which diarrhoea 
continued throughout the whole attack, so that my suspicion concerning 
typhoid continued until the localized area of inflammation formed. Fre- 
quently the symptoms of typhoid are so well marked that it is well to bear 
in mind the possibility of this disease. In other cases constipation was 
noted during the whole course of the disease. 

The diagnosis is usually not very difficult. A sudden pain localized in 
the right iliac fossa, associated with gastric or intestinal symptoms and 



APPENDICITIS. 281 

fever, should render the diagnosis easy. I rely upon the examination of 
the blood as an important guide in determining the presence of pus in the 
system. 

We must not mistake appendicitis for an abscess in the right ovary. 
The same can he differentiated by a careful vaginal examination. In young 
girls, where this is very difficult, an examination can be made with greater 
ease in the rectum. By means of bimanual palpation we can usually dif- 
ferentiate the same. Acute intestinal obstruction occurs frequently in young 
children. When the obstruction is due to an intussusception, bloody dis- 
charges from the bowels are generally present. In intussusception the 
tumor is found either in the median line or in the left side, whereas in ap- 
pendicitis it occupies the right iliac fossa. When there is a strangulated gut 
due to a volvulus the pain is not localized. In this form of obstruction of 
the bowel there is usually stercoraceous vomiting. 

Hip-joint disease and tuberculosis might possibly be mistaken for ap- 
pendicitis. There are a great many cases in which a diagnosis will only be 
positive after the abdomen has been opened. 

An important aid in the diagnosis is the examination of the blood. A 
marked increase in the leucocytes occurs in appendicitis, and there is a 
marked decrease, leucopsenia, in typhoid fever. 

Differential Leucocyte Count. — When the polynuclear percentage is 
70 to 80, and there is a marked leucocytosis, we should suspect pus. This 
blood examination must be used to support the other symptoms indicating 
an empyema, an appendicitis, or a mastoid — in fact, any suppurative 
condition. 

In studying the leucocytes by the daily blood examination there are 
certain positive indications. Steadily increasing leucocytosis demands 
operation. Steadily decreasing leucocytosis is a favorable symptom, and 
contraindicates the necessity for an operation. 

Course and Prognosis.— The prognosis depends on the time when treat- 
ment is commenced. A mild case of appendicitis may resemble colic with 
a slight rise of temperature and pass off unnoticed. If these attacks recur 
our suspicion should be aroused and the appendix removed. It is a good 
plan for the physician to call the surgeon in consultation when symptoms 
point to appendicitis. Very young infants do not bear laparotomy well, 
owing to the shock caused thereby, but if the surgeon operates rapidly 
shock is greatly lessened. Cases of appendicitis frequently assume a chronic 
course. Attacks may recur at intervals of weeks or months. If the diag- 
nosis is positive, it is much wiser to operate during the intervals of health 
rather than run the risk of a fatal complication such as peritonitis. 

Treatment. — First and foremost, absolute rest in bed. Until the diag- 
nosis is positive, the diet should be restricted to strained soups, skimmed 



282 DISEASES OF THE INTESTINES. 

milk, and weak tea for thirst. All starchy food should be excluded; hence 
neither bread, cereals, nor potatoes should be permitted. The choice be- 
tween hot-water bags and ice-bags depends on individual experience. An 
ice-bag is soothing to children. The application of several leeches in the 
early stage of the disease will sometimes prove beneficial. It is of impor- 
tance to see that the bowels have an evacuation once or twice in each 
twenty-four hours. While it is desirable to have an evacuation, no active 
catharsis should be prescribed. Do not stir up the abdomen with drugs, as it 
will positively do harm. To relieve the constipation, an enema of 1 pint of 
soap water and 1 ounce of glycerine will evacuate the stagnant faeces. This 
enema may be repeated daily until the acute attack has subsided. If vomit- 
ing persists cracked ice and champagne may be given. The value of opium 
is disputed by many. It certainly relieves pain, but prevents peristalsis. My 
choice has been codeine, 1 / ;!0 grain, increased to 1 / 6 grain, repeated every 
hour, depending on the age of the child, until the pain was relieved. ' 

If the symptoms continue in spite of the above treatment, .it is pos- 
sible that medical treatment is insufficient. No time should be lost, but 
prompt surgical relief should be given. 

The Time to Operate. — If a child has had a series of attacks of ap- 
pendicitis, then it is well to operate after a thorough convalescence. This 
operation is termed the "interval operation." During the interval between 
the attacks the physical condition of the patient is usually better. Great 
stress should be laid on what I have previously mentioned regarding the 
blood examination with especial reference to the leucocyte count and the 
percentage of polynuclear neutrophiles. If we have a high polynucleosis 
with a corresponding leucocytosis, then an operation is indicated. 

There are a few guides which may be of assistance when the blood is 
examined from day to day. Daily variations in the leucocyte count in a 
suspicious appendicitis are doubtful. If the leucocytosis is stationary, then 
the abscess may be walled off. If the leucocytosis increases it means a 
spreading abscess. When the leucocytosis declines from day to day it means 
a favorable course and operation may be postponed. 

If a general peritonitis is present operative interference must not be 
delayed. It is in this class of cases that we find a general septic process 
and in which, in addition to the local manifestations, we have a general 
systemic infection. 

Pseudo-appendicitis. 

In atony of the bowel we frequently have impacted faeces. In sUch 
cases I have known constipation to cause colicky pains and sudden cramps, 
so that the children would cry out suddenly. Belief was quickly afforded 
by a high soapsuds enema, which, brought away the offending masses of 
hardened fasces. Fever is frequently an accompaniment of constipation. 



PSEUDO-APPENDICITIS. 283 

It is therefore an important matter to exclude all other factors before 
resorting to extreme measures and advising an appendectomy. The fol- 
lowing two cases were reported by me in Pediatrics, Vol. XIII, No. 1, 
1902 :— 

Case I. — Maggie W., 10 years old, was perfectly healthy until the time of her 
present illness. She was suddenly attacked with pain, which was localized in the right 
hypochondriac region; the pain was very acute and was increased on pressure; the 
abdomen was distended and quite tympanitic on percussion; there was a marked 
dullness in the ileocecal region; there Avas an intense vomiting, the vomit containing 
particles of food along with mucus and bile and had a very offensive odor. The 
child vomited several times in one hour and seemed to vomit whenever the pain was 
most acute. The mother stated that the child had a regular movement of the bowels 
once in twenty-four hours, that she had had a movement that day and that her 
appetite had been quite good. She was a very strong and well-nourished child with 
no evidence of organic disease; there was no hysterical element; the child complained 
of no other pain but that directed to this abdominal condition ; there was a history 
of improper diet but no history of traumatism; the heart-sounds were normal; no 
murmurs were audible, the lungs were normal on percussion and auscultation; the 
liver did not seem to be enlarged; the spleen was palpable but not enlarged; the 
temperature was 104° F., taken in the rectum; pulse, 110; respiration, 20. 

When first seen an ice-bag had been applied over the most tender spot in the 
abdomen. Codeine in V -grain doses had been administered and a liquid diet pre- 
scribed. The child was first seen by me about twenty hours after the commencement 
of her illness with the above-named conditions. As this case had been seen by 
another colleague I was requested to meet him in consultation. The diagnosis of 
perityphlitic abscess had been made and an operation advised. The diagnosis was 
not so positive owing to the history of overeating. The child partook of many 
kinds of cake and pastries while, celebrating a birthday, and an overloaded stomach 
appeared most plausible. Hence an acute catarrhal gastritis was diagnosed. The 
pain and tenderness in the abdomen was ascribed to a colicky condition, resulting 
from fermentative processes in the stomach and extending into the intestine. The 
indication was to cleanse the stomach and bowels as rapidly as possible and thus 
remove the toxsemic condition which existed. Meanwhile an operation was not con- 
sidered until after the above measures were used. 

The urine was examined and showed a large excess of phosphates; no albumin, 
no sugar, no casts, no diazo-reaction; hence we excluded typhoid. There was a very 
strong indican reaction and this latter strengthened the diagnosis of fermentation 
due to intestinal putrefaction. 

The Treatment. — I suggested the use of a very. high enema with a long tube 
reaching into the colon; the enema consisting of 1 pint of glycerine diluted with 2 
pints of warm water; the temperature of the same was 102° F. The enema was 
very effectual and brought away a large amount of gas. The temperature which, 
as above stated, was 104° F., fell to 102° F. within one hour and gradually returned 
to normal in twelve hours, although no other antipyretic measure was used. Small 
doses of citrate of magnesia were ordered, a tablespoonful hourly, to quench thirst 
and at the same time to have a slight laxative effect. A liquid diet was continued, 
and thirty-six hours after the above remedies were ordered the child was in a 
normal condition. 

Case II. — A female child, about 10 years old, was seen by me through the 
courtesy of Dr. L. Harris, with severe abdominal symptoms. The most prominent 



284 DISEASES OF THE INTESTINES. 

symptom was an intense pain localized in the right hypochondriac region, more espe- 
cially in the ileocecal region. There was a marked distention of the whole abdomen; 
there was constipation and vomiting; the temperature ranged between 102° and 
103° F.; the pulse, which was 110, rose to 120. The child complained of an intense 
headache; in the beginning she also had a chill. The history, as given to me by 
Dr. Harris, was that the child had fallen from a fence on which she was standing, in 
the yard, a distance of about three feet. He believed that she had injured herself. 
The doctor's diagnosis was peritonitis from traumatism. In this diagnosis I con- 
curred. There was no distinct localized area of pain, but rather a diffused area of 
pain extending over the whole of the abdomen, which was intensified in the immediate 
locality of the injury. There were no chills; there were no rigors; the tempera- 
ture rose gradually; there was no evidence of suppuration and none suspected. 
The child was placed on a carefully restricted liquid diet, consisting of broth, soup, 
strained gruel, milk, egg albumin in various forms and in addition thereto opium in 
the form of deodorized tincture was given to alleviate pain. Attention was directed 
to the bowel and an enema was given to flush the rectum and colon and relieve 
accumulated faeces. 

Another colleague saw the child and diagnosed appendicitis, and suggested 
immediate operative treatment. I was again requested by the attending physician, 
Dr. Harris, to meet with this other colleague, and as a result, we decided not to 
have operative interference until we were satisfied that we were dealing with a puru- 
lent case. Palliative measures were used, such as ice, locally. In addition thereto 
the most absolute rest was enjoined, and the child made a brilliant recovery without 
an operation. We were satisfied that we were dealing with a traumatic peritonitis 
in which the local area of pain was due to the traumatism. 

A careful review of the above two cases will show that when the diag- 
nosis of appendicitis is made by a process of exclusion then greater care 
should be exercised before resorting to extreme measures. 

In the first case the high temperature and the suddenness of the 
attack certainly showed^ marked symptoms pointing toward appendicitis. 
The high temperature was clue to the toxemic condition resulting from 
impacted fasces. The pain was an enteralgia due to a distended gut filled 
with gas. Such colicky conditions are so frequent in young infants that 
we could operate very frequently if the diagnosis of appendicitis were made 
every time an infant screams with pain. The cases above reported are very 
interesting as showing that cases will frequently have symptoms resembling 
perityphlitis or perityphlitic abscess, so that a differential diagnosis will be 
very hard to make. Not infrequently cases of appendicitis will be over- 
looked, and when such is the case, if they are of the catarrhal type, no 
harm will ensue therefrom. On the other hand, I must not be understood 
as disparaging the idea that no case of appendicitis requires an operation, 
but my object in calling attention to these two cases is to offer a plea that 
before a case of supposed appendicitis is subjected to an operation, that we 
should be sure that all other conditions, such as impacted fasces, as in my 
first case, and other allied conditions have been excluded in the diagnosis. 



INTUSSUSCEPTION. 285 

AtJTO-IXTOXICATIOX. 

In very young infants auto-intoxication of the intestines is caused by 
protein or fatty indigestion and fermentation, and is one of the most fre- 
quent causes of high fever. 

Too frequent feeding, or the feeding of food containing a high fat or 
excessive protein suitable for the infant, provokes dyspeptic indigestion. 
From this indigestion we have fever and the products of decomposition 
resulting in toxaemia. If this toxaemia continues convulsions frequently 
follow. 

Another common form of auto-intoxication met with is due to stagnant 
faeces. An impacted stool, especially if atony of the intestine exists will 
frequently cause a rise of temperature and give marked systemic disturb- 
ances such as loss of appetite and headache. The abdomen is distended, 
notably the transverse colon. The urine is high colored and gives an 
indican reaction. 

The treatment consists in relieving the bowels by an injection of one 
pint of soap water. Internally 5 grains of compound jalap powder with 2 
grains of calomel should be given. Milk should be stopped. Whey or 
thin broths should be given for at least twenty-four hours. Water liberally 
is required. 

Intussusception. 

The most frequent form of obstruction of the bowel is that known as 
intussusception, or invagination of the bowel. 

Intussusception involves three layers of the bowel, each layer consist- 
ing of all the intestinal coats: First^the outer layer is known as the intus- 
suscipiens, the sheath or receiving layer; second, the internal is known 
as the entering layer which, together with the third, the middle or return- 
ing layer, constitutes the invaginated part known as the intussusceptum. 

The clinical records show that about one-half of all cases occur at the 
junction of the small and large intestine. 

When the ileum becomes invaginated in the colon, the condition 
is termed ileo-colic intussusception. 

In less than one-third of all cases invagination takes place in the small 
intestine. This is known as ileal or jejunal intussusception. When this 
invagination takes place only in the large intestine it is called colic intus- 
susception. 

This usually commences at the ileo-caecal valve and extends down- 
ward. It is felt as a tumor much larger than the swelling found in appen- 
dicitis. 

Intussusception usually causes a recession of the abdomen from the 
side of the eweum, while appendicitis, if it does anything, will at least 
prevent recession of the abdominal walls at this point. 



286 DISEASES OF THE INTESTINES. 

Symptoms and Diagnosis. — Nausea and vomiting are among the earliest 
symptoms. Later in the disease the vomit becomes faecal (so-called ster- 
coraceous vomit) in character. The child has pain; assumes the dorsal 
position with the thighs drawn up on the abdomen. The pain appears in 
paroxysms, accompanied with a discharge of blood and mucus. Eectal 
tenesmus also is present. The temperature ranges between 101° and 103° F. 
The pulse from 120 to 150 per minute. 

Cases that give a clear history of intestinal obstruction with no stool 
passing, and vomiting caused by such obstruction, offer a good prognosis if 
operated early. Continued vomiting of food will cause exhaustion and rob 
the infant of the vitality necessary to undergo the shock caused by the 
operation. 

The following case will illustrate intussusception as met with in gen- 
eral practice. The history was as follows : — 

Infant B., five months old, had vomited for some time; was constipated, having 
had no stool for several days. The temperature was about normal; the abdomen 
was distended. The child was breast-fed. The breast was discontinued for a short 
time and barley water substituted to relieve the vomiting. 

a . ^ k 



STOMACH, , ASV8. 



Fig. 81. — Mechanism of Intussusception (Treves). The sheath at A. 
passes to B, then to C. The lower part of the intestine is drawn over the 
upper instead of the upper crowded into the lower. For a fuller description 
see Treves's "Intestinal Obstruction," London, 1884. 

Through courtesy of Dr. A. E. Isaacs, of this city, I saw the child several times 
in consultation. 

The vomiting continued in spite of the withdrawal of the breast-milk. Par- 
oxysms of pain constantly recurring. Infant screaming. Repeated enemas did not 
result in emptying the bowels. Calomel had been given in both large and small doses 
with no satisfactory result. In addition thereto cathartics had been given. The 
vomiting persisted; at the same time the distention in the abdomen continued. The 
diagnosis intussusception was made and an operation suggested. The family objected 
to an operation and palliative measures were used. The child died several days 
later. The symptoms which were most marked in this case were: — 

1. Continued vomiting. 

2. Fsecal impaction, the gut being so obstructed that no faeces passed in more 
than ten days, though flatus would occasionally pass. 

3. During the first two or three days not only was clear blood passed per 
rectum, but large masses of jelly-like mucus tinged with blood were frequently ex- 
pelled from the rectum until the end. 

4. The distended belly, the abdomen abnormally distended, and very tympanitic 
on percussion. 

5. The absence of all inflammatory symptoms such as rise of temperature until 
two days before the death of the patient, when the temperature rose to 101° F. and 
the pulse rose to 160. 



PLATE VIII 




Intussusception. (Courtesy of Br. Reu.) 



PLATE IX 




Intussusception. (Courtesy cf Dr. Reu. 



INTUSSUSCEPTION. 287 

6. Continued crying; the child with rare exceptions showed evidences of pain. 

There was no positive etiological factor in this case, as there were two other 
healthy children in this family; the father and mother were in apparent good 
health. There was no evidence of traumatism nor anything that could be connected 
with the cause of this condition. The mother stated that for a period of two months 
before the appearance of this condition she had given a patent cathartic every day, 
as she thought, with advantage. Whether or no. this drug had anything to do witn 
this condition it is difficult to state. The presumption is, however, that the con- 
tinued effect of giving cathartics was indirectly the cause. 

In the above-reported case an operation was refused and the child 
died. The chances were in its favor : — ■ 

1. Because it was a well-developed and well-nourished baby. 

2. Because it was breast-fed. 

3. Because the diagnosis was made very early in the disease. 

4. Because the heart's action was very good, and no chronic or infec- 
tious disease existed. 

In 1870 Pilz 1 reported 94 cases under 1 year — mortality, 84 per cent. 
From 1870 to 1891 135 cases, under 1 year, gave mortality of 59 per cent. 

The reduction in percentage of mortality in recent years is evidently 
due to modern aseptic surgery. Whereas formerly recovery depended on 
sloughing, to-day laparotomy is the rule. 

Two interesting clinical points which I have made use of are given by 
Caille:— 

1. Try to reduce the obstruction by non-operative means — injections 
of oil — the child in an inverted position following the injection; gentle 
manipulation of the abdomen. 

2. In percussing the abdomen there will generally be found at the 
site of the obstruction a very tympanitic area adjoining a dull area. By 
carefully noting this point the surgeon has an important landmark for his 
guidance in performing the operation. 

Prognosis. — Without operation the prognosis is exceedingly bad. The 
earlier the operation, the better the result. In some cases Nature relieves 
the invagination and a slough will separate. This is, however, a rare con- 
dition. 

Treatment. — -When the diagnosis is established no time should be lost. 
Inflation of the towel with air or hydrogen through a long rubber tube 
has been recommended. When this is not successful the child may be in- 
verted and gentle manipulation of the abdomen may be attempted. 

Injections may be given with or without anaesthesia. The baby is 
turned on its belly; the hips are raised by gently supporting the abdomen 
on a soft pillow. The mouth and nose, being the lowest part of the body, 
must be protected. The baby is then anaesthetized with chloroform, and 
warm water is poured into the rectum with but little pressure, from a 



1 Jahrbuch fur Kinderheilkunde. Bd. iii, p. 6. 



288 



DISEASES OF THE INTESTINES. 



height not exceeding three feet. The injection is frequently intermitted, 
while the anus is closed with a cotton ping held by the finger. At the 
same time the abdomen, in the direction from below upward, is gently 
kneaded and its contents moved about. 

Unless this proves successful no time should be lost and an abdominal 
operation should be performed. 

Although surgical interference offers the best means of treatment, we 
should note the condition of the child at the time of operation, and con- 
sider the result of shock and haemorrhage in estimating the therapeutic 
result. No cathartics should be given after the operation, but the bowels 
should be confined by administering a small dose of opium. Stimulation 




Fig. 82. — Umbilical Hernia. The result of violent paroxysms of 
whooping-cough. (Original.) 

will be urgently demanded; hence whisky or iced champagne should be 
given db libitum. It is well to remember that very young children do 
not offer good resistance to the shock of an abdominal section. Fully 50 
per cent, of cases seen by me were fatal. The details of an operation for 
intussusception are those of aseptic surgery, for which my readers are 
referred to the special books on surgery. Dr. John F. Erdman, of New 
York City, has reported a series of successful operations in very young 
children. 

Umbilical Hernia. 1 

This condition is frequently seen in both male and female children. 
It is more often seen in the female. 

Causes. — It is usually found in children with flabby muscles such as 
rachitic and atrophied cases. Severe abdominal strain during the parox- 
ysms of whooping-cough or in continued constipation frequently results 



1 For Inguinal Hernia, see chapter on "Diseases of the Genito-Urinary Tract." 



PLATE X 



















\ I 
■ 

■ 11 / ^r\ 1 K 




mm WL 




■ ' \ 1 










' 







Cestodes (Tape-worms). 1, Taenia saginata. A, Head of taenia sagi- 
nata. 2, Dorsal view of the head. 3. Apex view of head, showing depres- 
sion in center. .'/. Isolated, elongated segments. 5, Bothriocephalic latus. 

6, Ripe segments of taenia saginata. B, showing location of sexual organs. 

7, Half-developed segments of taenia saginata. Illustrations drawn from 
specimens. ( Original. ) 



TAPEWORM. - 289 

in umbilical hernia. The tumor may be from one-half to one inch wide, 
and the same also in length. 

Treatment. — Preventive Treatment: After the umbilical cord has 
separated, the usual flannel binder may be used to lend support to the 
abdomen for the first two or three months. 

Mechanical Treatment. — A pad of absorbent cotton into which a thick 
piece of cork or a wooden button the size of a 25-cent-piece is wrapped, 
should be snugly pressed over the protruding part and secured by thick 
straps of zinc oxide plaster. This dressing should be renewed every four 
or five days. The treatment must be continued for several months. 

A truss consisting of a rubber pad and a belt to pass around the 
body should be applied so that it cannot slip and has enough pressure to 
keep the hernia in place. 



Fig. 83. — Umbilical Hernia Truss. 

Tapeworm (Cestodes). 

The tapeworm enters the body by food containing the larva?. Sev- 
eral varieties are met with. When the worm is fully developed it consists 
of rectangular segments or pieces. These segments are also called pro- 
glottides. The head and neck of the worm are called scolex. 

The eggs (larvae) of the taenia solium are found in pork; taenia 
mediocanellata, in beef; bothriocephalus latus, in fish; taenia cucumerina, 
in dogs and cats. 

Development of the Worm. — A worm develops in about three months. 
When the terminal segments are mature they separate and are discharged 
in the stool. As each segment contains both male and female organs, each 
one is capable of regenerating a whole worm. For this very reason the 
treatment of a tapeworm will never be successful until the head and every 
segment has been expelled. Tapeworms are estimated to live from ten to 
twenty, and possibly, thirty years. 

The beef tapeworm is the most frequent found in children. It has 
four suckers, a square head, and no hooks. Raw meat may contain the 
cysticerci. 

The pork tapeworm is the rarest found in children. The head has 
four suckers, surrounding which there is a circle of about twenty-six hooks. 
The length of the worm varies from ten to fifty feet. Nursing children 
are exempt from tapeworm. 



290 DISEASES OF THE INTESTINES. 

Symptoms. — In children between 2 and 4 years of age subjective 
symptoms are difficult to interpret. In older children we will notice at- 
tacks simulating colic associated with fairly good movements of the 
bowels. There is restlessness at night and marked nervous irritability by 
day. The breath is foul and the child presents evidences of marked 
anaemia. In spite of an abnormally large appetite the body wastes and 
the child is believed to suffer with some latent form of tuberculosis. 

Diagnosis. — The diagnosis is positive only when segments of the worm 
are found. The absence of cough or pulmonary symptoms will usually aid 
in excluding tuberculosis. At times several weeks will pass before a posi- 
tive diagnosis can be made. 

Prognosis. — The prognosis is usually good. It is simply necessary to 
use radical treatment to dislodge and sicken the worm and then expel it. 

Treatment. — The tsenicide should be given after fasting and followed 
in an hour by a cathartic to carry off the worm. The best taenicides are 
pomegranate or its alkaloid, pelletierine; filix mas; kousso; pumpkin- 
seed, and turpentine. 

Ifc Oleores. fills mas 1^ drachms 

Chloroform 10 drops 

Syr. ginger q. s. ad 1 ounce 

M. Sig. : Divide into two parts. Take on empty stomach, half -hour apart. 

For a child ten years old, younger children one-half the dose. 

1$. Tannate of pelletierine % grain 

Sig.: For a child 3 to 5 years old (T. M. Rotch) . 

I£ Olei terebinthinse 1 fluidrachm 

Olei ricini ^ ounce 

M. Sig.: Take it in one dose (Farqhuarson). 

Since entire expulsion of the tapeworm is effected with difficulty, 
preparatory treatment for about forty-eight hours should be employed 
before the vermifuge is administered. During this time the patient should 
take a mild purgative once or twice, and such food in moderate quantity 
should be allowed as leaves little residuum, as beef-tea, etc., with some 
stimulant if the patient feels exhausted. There are three articles of food 
which experience has shown to be especially useful in this preparatory 
treatment, perhaps from a sickening effect which they produce upon the 
worm, namely, salt herrings, onions, and garlic. This may, therefore, be 
taken as food in the twelve or eighteen hours preceding the employment 
of the vermifuge, which it is ordinarily most convenient to administer in 
the morning. 

ASCARIS LUMBRICOIDES (ROUND WORM). 

This worm is a reddish or yellowish round worm, usually from 5 to 
10 inches long. The male worm is smaller than the female. This worm 



ASCARIS LUMBRICOIDES. 291 

inhabits the small intestines. It is seldom found solitary, but usually 4 
to 10 may be present. Some authors state that as many as 200 and 300 
have been found at one time. The worm is usually found in children 
between the second and tenth years. It is never found in nurslings. These 
worms will wander from the small intestines into the stomach and irritate 
the gastric mucosa. They are frequently expelled by vomiting. 

A child 4 years old was seen by me during my service at the Willard Parker 
Hospital in the fall of 1903. The child had pharyngeal and tonsillar diphtheria. It 
was a septic type of diphtheria. The child vomited a round worm about 6 inches 
long on the second day after admission. On the third day another worm about 5 
inches long was also ejected by vomiting. There were no symptoms pointing to the 
presence of these round worms. 

Some authors report worms wandering into the nose and also into 
the middle ear. A worm entering the larynx has produced fatal asphyxia. 
Another author reports jaundice due to worms entering the common bile 
duct. Worms have been known to produce hepatic abscesses. They have 
been found in the vermiform appendix. These worms appear most fre- 
quently in the stools. They have been found in umbilical abscesses. 

Symptoms. — Very indefinite symptoms can be ascribed to these round 
worms. Irritation, such as restlessness at night, grinding of teeth, picking 
the nose, and scratching the anus. Abdominal symptoms, such as colic, 
diarrhcea, and tympanites, are frequent. This clinical picture must not 
be presumed to be present in all cases. Not infrequently symptoms of 
meningitis will be mistaken for worms. Be sure to exclude all other con- 
ditions before expressing a positive opinion. Nervous symptoms, such as 
hysteria, vertigo, and epileptiform convulsions, have been noted while 
worms existed. As these conditions disappeared when the worms were 
expelled, it is but fair to presume that they were indirectly the cause of 
these nervous manifestations. 

Diagnosis. — A positive diagnosis can only be made if the round worms 
are discharged from the body or if the ova are discovered in the stool. The 
microscopical examination, therefore, is very valuable and should always 
be made when in doubt. If the ova are still found in the stool after one 
or two worms have been expelled, then more worms should be suspected. 

Prognosis. — The prognosis is always good, but the child must be kept 
under constant observation for at least several months. 

Treatment. — To eliminate worms from the body, the tamicide should 
be given for several days and then followed by a brisk cathartic. The fol- 
lowing formulas have served me very well: — 

I£ Magnesii sulphatis 4 drachms 

Syrupi rubi idaei 2 fluid ounces 

M. Sig. : A tablespoonful two or three times a week, to be preceded by 
santonin, 1 spigelia, or chenopodium. Once a day a high enema of soapy water should 

1 The formula for santonin is given in the chapter on "Oxyuris Vermicularis," 



292 DISEASES OF THE INTESTINES. 

be given. The folds of the anus should be carefully cleansed with soap and water, 
and the following ointment applied: — 

IJ Acidi borici 1 drachm 

Olei rosse 3 drops 

Vaseline 1 ounce 

M. Sig.: Apply externally. 

Other tsenicides recommended by Townsend are : — 

IJ Ext. spigeliae 10 fluid ounces 

Ext. sennse 6 fluid ounces 

Olei anisi 20 minims 

Olei cari 20 minims 

M. Sig.: Half-teaspoonful for a child 2 years old, two or three times daily. 
Teaspoonful for a child from 4 to 10 years old. 

Or:— 

Ifc Oil of chenopodium 2 drachms 

Sig. : To be given on sugar three times daily, in doses of 5 drops, to a child of 

3 years. Ten drops to a child of 10 years. A cathartic should be given every 

second or third day. 

r] ', Oxyuris Vermicularis (Pinworm; Threadworm). 

The female worm is thin, yellowish white, and has a pointed tail. 
The male has a strongly curved tail. The male worm is rarely found in 
the stool. The female worm is present in greater number than the male. 
The oxyuris is frequently passed in the mucus during a catarrhal discharge 
from the rectum. These worms frequently wander from the rectum into 
the vagina. 

Symptoms. — Irritation and itching of the anus, causing restlessness 
and severe nervous manifestations, usually appear after the child is in a 
warm bed. The itching frequently gives rise to a desire for frequent 
urination. In severe cases it may lead to masturbation. The constant 
scratching to relieve the itching has produced vulvitis and vaginitis. Con- 
vulsions have been brought on by reflex irritation due to the presence 
of worms. 

Treatment. — Threadworms are most effectually and easily removed 
by the use of enemata. For this purpose lime water, or an infusion of 
quassia, or solution of common salt (a teaspoonful of salt to 4 ounces 
of water) may be employed. In using these agents the bowels should first 
be cleansed by a copious injection of warm water. Jacobi recommends a 
decoction of garlic as an enema in these cases. 

IJ Santonin 1 to 2 grains 

Mild chloride of mercury % grain 

M. Sig.: Every night for two or three nights, to a child 5 or 6 years old, 
and followed each morning by a purgative dose of castor-oil. 



UNCINARIASIS. 293 

Or:— 

Ifc Santonin 1 grain 

Compound liquorice powder 2 drachms 

(Eustace Smith.) 

Uncinariasis (Hookworm Disease). 

The American worm was discovered in 1899 by Dr. Bailey K. Ashford. 
It is named Necator americanus. It is about half an inch in length, and 
has the appearance of soiled spool cotton. The larvae enter the system 
through the soles of the feet, and finally lodge in the intestinal tract. 

The symptoms are extreme pallor of the skin, profound anaemia, ex- 
cessive appetite, occasional abdominal pains, and tenderness. The bowels 
may be constipated or loose ; the stool is foetid. There is palpitation of the 
heart — a haemic murmur. Haemoglobin percentage drops to between 30 and 
60 and the red cells from 3,500,000 to 4,000,000 per cubic centimeter. 
There is a marked eosinophilia. There is marked weakness and a disin- 
clination to play. 

When the symptoms are more severe, there is an oedema of the feet 
and ankles, and pufnness of the face is noted. Sometimes a jaundiced 
condition exists. Some cases show emaciation. The nervous system is dis- 
turbed, there is marked insomnia, and the urine contains traces of albumin, 
but no casts. 

The stools should be examined for the ova while fresh. The ova are 
found with greater ease in partially formed or soft stools. In preparing 
specimens a drop of water is placed on a clean slide and a bit of faecal matter 
is taken up on a platinum loop; this is thoroughly mixed and a cover glass 
placed over the specimen, after which it is examined with a 2 / 3 objective. 

Treatment consists in giving thymol in 5-grain doses, every hour for 
4 doses. In view of the toxic qualities of thymol, it is advisable to thor- 
oughly test the eucalyptus treatment, which is recommended by many treat- 
ing this disease. 

I£ Eucalyptus oil 2 drops 

Chloroform 1 drop 

Castor oil 2 drachms 

Sig. : One dose t. i. d. Repeat treatment several days. 

Chenopodium oil has been successfully used in the treatment of this 
disease. It should be given in 5- to 10- minim doses on a lump of sugar, 
and repeated if necessary in two-hour intervals until three doses have been 
taken. After the last dose several teaspoonfuls of castor oil should be given. 



CHAPTEEV. 
DISEASES OF THE RECTUM. 

Fissure of the Anus. 

An ulcer having its long diameter parallel with the long axis of the 
bowel is occasionally met with. It occurs at the anal margin. It is seen 
in infants as well as in older children. It is caused by the passage of 
irritating hard faecal masses. It is also occasionally seen after prolonged 
diarrhoea with continuous straining. Some authors state that traumatism 
from the nozzle of a syringe may cause a fissure. This I have never been 
able to verify. Streaks of blood of a bright red color will usually be seen 
in the stools when a fissure is present. 

The prognosis is good. 

Treatment. — This should be mainly hygienic, and consist in thorough 
cleansing of the parts. The application of solid nitrate of silver will 
usually effect a cure. The bowel should be relieved daily by the injection 
of sweet-oil or glycerine to soften the faeces. Some authors advise stretch- 
ing the sphincter of the anus and keeping the parts at rest. • 

Simple Catarrhal Proctitis. 

The rectum is rarely inflamed without additional portions of the 
bowel being involved. When the same exists, local causes must be looked 
for; for example, carelessness while irrigating the rectum. Mistakes, such 
as corroding or caustic drugs, can set up an inflammation. An instance 
of this kind occurred in my practice when a child received a strong injec- 
tion of carbolic acid, causing inflammation. Infection extending from 
the vagina or urethra, such as gonorrhoea or diphtheria, can cause this 
condition. Syphilis has been known to affect the rectum. In simple ca- 
tarrh the pathological lesions are the same as those found higher up in the 
gut. 

The symptoms are pain when the bowels move. The stool contains 
mucus, which may be distinctly separate. When folds of mucous membrane 
protrude they are very angry looking and show a deep red pigmentation. 
Children old enough will complain of intense burning and itching. 

The treatment consists in using bland injections such as oatmeal 
water or starch water; when severe tenesmus exists, bicarbonate of soda, 
a teaspoonful to a pint of water, is beneficial. 

(294) 



ISCHIORECTAL ABSCESS. 095 



Croupous Proctitis. 

This is the form usually associated with diphtheria of the genitals. 
Large arid small pieces of mucous membrane are found mixed with the 
stool. Pathogenic bacteria, such as the streptococci and staphylococci, are 
found in the dejecta. 

The treatment consists in using bland antiseptic irrigations, bichlo- 
ride of mercury, 1 to 5000, or a normal saline solution, repeated several 
times a day. If diphtheria is present, antitoxin should be given (see 
chapter on '''Antitoxin"). 

If syphilis is present the usual treatment for the same (see chapter 
on "Syphilis") is indicated. 

Ulcerative Proctitis. 

Tuberculous ulceration of the rectum has been reported by Steffen; 
also by Holt. Syphilitic ulcers are rare in children. There is usually 
bleeding and tenesmus. The blood is of a bright red color. The diagnosis 
is easily made by examination with a speculum and by no other means. 

The treatment is very difficult. First, cleanse the rectum. Apply, 
locally, nitrate of silver with the aid of a speculum. The insufflation of 
iodoform, dermatol, or europhen is very useful. 

HAEMORRHOIDS. 

This condition is occasionally met with in children. It usually ac- 
companies chronic constipation. The persistent constipation associated 
with cretinism occasionally causes this condition. 

An instance of this kind was seen by me in a child about 2H years old, which 
was referred to me because it could neither walk nor talk. It had been operated 
for congenital adenoids by Dr. W. Freudenthal. The case had been under the treat- 
ment of Dr. A. Jacobi for one year. In this case chronic constipation was associated 
with haemorrhoids. The stool was so hard and dry that blood was occasionally 
found after severe tenesmus. Thyroid treatment was directed against the cretinism, 
and malt extract ordered to overcome the constipation. 

The usual treatment consists in removing the cause as much as pos- 
sible as above described. 

I have never met with a case under 12 years of age that required 
operation, although instances of this kind are occasionally described in 
surgical literature. 

ISCHIO-RECTAL ABSCESS. 

In excoriated conditions around the anus, following continued diar- 
rhoea, an infection frequently results from scratching. Pyogenic bac- 
teria undoubtedly enter the lymph channels. 



296 DISEASES OF THE RECTUM. 

A case of this kind was seen by me in the family of Dr. J. Grosner, of New 
York City. An infant nursing at the breast had dyspeptic symptoms, such as flatu- 
lence, and, later, intestinal catarrh. An ischio-rectal abscess developed later on. It 
was benign and required a simple incision with careful attention to asepsis. This 
condition lasted in all about two weeks. The child made a splendid recovery. 

At times we meet with very deep-seated inflammation which requires 
the skill of the surgeon. When a fistula exists proper surgical treatment is 
indicated. 

Prolapsus Ani. 

When children strain, especially during constipation, prolapse of the 
anus frequently follows. Not infrequently as much as one or two inches 
cf the mucous membrane protrudes. (See Fig. 114.) 

Causes. — There are three main causes: First, weakness of the levator 
ani muscles. In general atonic conditions — for example, in rickets — this 
condition frequently follows constipation, the constipation being a part 
of the rickety condition and indirectly causing a straining during defeca- 
tion, thus ending in prolapse of the rectum. Deficient peristalsis, espe- 
cially in young children, induces them to strain to expel hardened faecal 
matter. On the other hand constant diarrhoea and irritation in the lower 
bowel may also result in prolapse. When an attack of summer complaint 
nas lasted a long time, w T e usually find at the end of defecation that the 
rectum protrudes. 

Second, when the ischio-rectal fat is deficient. In marasmic condi- 
tions, such as in athrepsia infantum or following the acute infectious dis- 
eases, when high fever and general wasting have taken, place, the body fat 
surfers, and so the mechanical support of the rectum is lost. 

Third, traumatic condition. This condition is frequently induced 
by coughing paroxysms, hence it not infrequently follows whooping-cough. 
Eetention of urine, phimosis, and vesical calculi may cause this condition. 

Diagnosis. — The size and the location of the tumor, and its appear- 
ance during the straining while at stool, render the diagnosis easy. The 
ease with which the prolapse can be replaced is noteworthy in making a 
diagnosis. It is rare for this condition to be mistaken for intussusception 
(see chapter on "Intussusception"). 

Treatment. — Local: Place the child in the knee-chest position and 
apply olive-oil to the prolapsed bowel, after which the gut can be replaced. 
When this mild manner of reduction is not successful, a whiff of chloro- 
form should be used to quiet the child. This will also relax the protruding 
part. After replacing the gut the buttocks should be supported by a stout 
strap of adhesive plaster running from side to side. Cold water irrigations 
should be given. These will have the two-fold object of emptying the 



RECTAL POLYPI. 297 

lower bowel as well as toning the muscle. Astringent injections of sulphate 
of zinc, 1 grain to the ounce, or tannic acid, 10 grains to the ounce, are 
recommended by some. I have failed to see any benefit therefrom. The 
local application of the tincture of the chloride of iron once every three 
days has seemed to be of some benefit. The solid stick of nitrate of silver 
or cauterization by means of the Paquelin cautery, made red hot, is fre- 
quently recommended. Heroic measures, such as amputation of the parts, 
are rarely, if ever, necessary. 

Constitutional Treatment.— We must not expect to cure a condition 
of this kind unless the body is strengthened. Eestoratives, cereals, eggs, 
and milk must be prescribed. We can supply a deficiency of fat by order- 
ing codliver-oil or lipanin, 1 teaspoonful three times a day. When con- 
stipation exists the addition of malt, as in a malted food, will aid this 
condition. Strychnine may be given in doses of 1 / 100 of a grain, and 
increased gradually until 1 / G0 of a grain is given, three times a day. Iron 
can also be given with great advantage. Massage of the abdomen and 
electricity must not be forgotten. A cold shower or spray over the spine 
and abdomen, repeated every day, is an excellent tonic. 



Eectal Polypi. 

Polypus of the rectum is very common in early life. When bleeding 
occurs it may be due to a fissure or to a hard sc} 7 balous stool tearing 
the mucous membrane. It may be caused by a rectal polypus. Frequently 
we find this condition in syphilis. 

The treatment consists in tying off the polypus with fine catgut or 
snipping the polypus with a scissors and then cauterizing the base. 



CHAPTER VI. 

DEFICIENCY DISEASES AND DISORDERS ARISING FROM THE IMPROPER 

ASSIMILATION OF NUTRITION WHEREBY FAULTY 

METABOLISM RESULTS. 

Faulty Metabolism. 

This condition is primarily due to faulty feeding, or to conditions asso- 
ciated with improper nutrition whereby faulty metabolism results. It is 
found in infancy, but is also very prevalent in older children between the 
ages of 4 and 14 years. We find a subnormal condition of the skin which 
may be cold or moist, or the skin may be found dry, and the circulation 
poor. The extremities are cold; cyanosis is not present. Such children 
frequently have marked vasomotor disturbances manifested by unilateral 
flushes of the face, of one ear, or the nose. The elasticity of the skin is 
much less than normal. Adipose tissue is usually lacking, although this 
type of case may be unusually fat. Such adiposity is due to faulty assimila- 
tion. The child shows the evidence of defective nutrition. It is underfed. 
If it is not underfed, then the food is not assimilated. Sometimes both 
quantity and quality of food are properly regulated and still subnormal 
conditions prevail. An absence of the internal secretions due to functional 
inactivity of various glands associated with the digestive tract is most 
probable because such cases have, first, 

Lienteric stools in which undigested particles of food may be found. 
Such lienteric condition may be modified by a stimulation of glandular 
activity, such as the salivary and peptic glands. We must not undervalue, 
the role played by the pancreatic ferments, and the necessity for that most 
important of all glands, namely, the liver. Inactivity on the part of the 
liver and the absence of a proper secretion of bile are two of the most 
potent factors in causing faulty metabolism. 

Second. Scybalous Stools. — When dry, round, faecal masses stagnate in 
the colon they set up a series of symptoms which yield one of the most 
frequent sources of trouble in children. In this type of stagnation of 
faeces, one of the prime causes is the absence of tone to the intestinal 
muscles, but the dryness and lack of secretion per se is due to the absence 
of proper lubrication from a subnormal mucous membrane. It is plain, 
therefore, that we must seek the origin of this trouble in a deficiency of the 
secretions previously named or in the absence of a proper secretion of bile. 
The bile salts, especially in infancy and childhood, have a most important 
bearing on the efficiency of digestion. Unless the liver performs its func- 
tion, faulty metabolism is inevitable. Whenever possible the urine should be 
examined for the presence of indican. Indicanuria usually accompanies- 

(298) 



FAULTY METABOLISM. 399, 

stagnation of intestinal contents, and is frequently associated with symptoms 
that make up a clinical picture of autointoxication of the intestine. Fever, 
so-called absorption fever, is usually a bi-product of this stagnation, and the 
temperature will range from 100° to 102° F. for many weeks, or until the 
diet is so reduced and the gastrointestinal tract so cleansed that intestinal 
stagnation is impossible. 

It is readily seen from what has just been said that faulty metabolism 
robs the bones of their proper nutrition, and by a deficient quantity of blood 
the nutrition is subnormal ; hence rickets due to soft bones results. A defi- 
ciency of lime salts in the bones is evident in the teeth, which show carious 
manifestations and a breaking clown, so-called chalky teeth. 

What applies to the bones is true also concerning the muscles. The 
muscles are flabby and soft, and show the lack of tone that good healthy 
muscular tissue should show. Such children are very restless at night; as a 
rule the general atony of the muscles of the bladder results in enuresis. 

The atony of the intestine is evident in deficient peristalsis and con- 
sequent coprostasis. The obstipation if present results from dryness and 
lack of secretion in the intestine ; hence scybalous stools are noted. 

Faulty metabolism is very evident in the nasopharyngeal tract. Such 
children have the adenoid habitus, they are prone to infections, and are 
constant sufferers from tonsillitis and swelling of the adenoid vegetations. 
The cervical glands are usually enlarged. These children are frequently 
victims of bronchitis and pneumonia. 

Owing to this subnormal condition the immunity of the body and the 
phagocytosis are so greatly minimized that such children not only invite all 
exanthematous infections but frequently succumb therefrom. Due tc this 
lack of vitality, one is not surprised to see a slight rhinitis extend through 
the Eustachian tube and set up an otitis media ending in mastoid infection. 
It is this class of cases which if first seen by the laryngologist will be 
treated by curetting adenoids if present, and likewise by the removal of 
tonsils if hypertrophied. 

Catarrhal Tendencies. — These cases are brought to the pediatrist weeks 
and months after such primary operation for the relief of three serious 
symptoms which were the reason for the nasopharyngeal treatment. These 
symptoms are : loss of appetite, no gain in weight, and general restlessness 
and irritability. These three symptoms stand out prominently in the picture 
which, summed together, spells faulty metabolism. 

Nervous Manifestations.— There is an irritability and sensitiveness 
simulating hysteria in the adult. Such children are easily dissatisfied. 
They cry on the slightest provocation. They are peevish and hard to please. 
This applies not only to their clothing, surroundiDgs and playmates, but, 
equally so, their food cravings are abnormal. They insist on sweets, also 
crave sour foods and condiments. Biting of the nails, thumb sucking and 



300 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

masturbation in the form of thigh friction may be started by an excoriation 
around the genitals and anus, caused by very acid or ammoniacal urine. 

I have been requested to examine such cases for a suspicion of tuber- 
culosis. The picture does resemble tuberculosis, although no tubercle bacilli 
exist in the expectoration. Such children will not give a cutaneous reaction 
when scarrified with tuberculin. The physical signs in the chest are 
negative, although rhonchi may occasionally be heard. 

These cases frequently have, a distinct resemblance to hereditary 
syphilis. The differential diagnosis can be determined by securing an 
honest family history, and noting the presence or absence of Hutchinson's 
teeth. If still in doubt with the absence of such important data, a Wasser- 
mann reaction will aid in establishing the diagnosis. Faulty metabolism is 
an important factor in tuberculosis as well as syphilis, and the exclusion of 
such diseases must be positive. There are thousands of children whose 
sallow appearance and shriveled skin imply an abnormal state of health 
which requires vigorous treatment if results are to be obtained. 

Treatment. — If we are dealing with a distended colon or distention of 
the stomach associated with flatulence or eructations of gas, then starches 
in all forms must be excluded. Potatoes, bread, cake, and all flour foods 
must be stopped. In addition thereto all cereals such as rice, barley, and 
cornstarch must be excluded. The stool should be examined to see whether 
it contains gaseous bubbles and mucus or whether the consistency is solid. 
In a young child a strict diet of milk, eggs, and cream cheese is indicated. 
An older child, besides milk, cheese, and eggs, may have junket, custard, fish, 
meat, and all green vegetables. Stewed fruits and fresh fruits are indicated. 
The question of assimilation of food depends greatly on a regular four or 
five hour interval between each meal, with fresh air and out-door exercise, 
and not overfilling or overtaxing the stomach with large meals. 

Nux vomica in doses of 1 to 5 drops before each meal, depending on 
the age of the child, is an excellent tonic. Pancreatin in doses of 1 or 2 
grains may be combined with the mux vomica. 

The weight is an important guide as to the progress of proper metabo- 
lism. A mild laxative such as 15 to 20 grains of calcined magnesia can be 
given every morning if necessary. The child must not be permitted to 
retire without an" evacuation of the bowel. One-half pint of soap-water 
may be given as an enema if necessary. 

A change of air from the city to the seashore for several months during 
winter or summer will frequently aid in establishing normal conditions. 
Some children will be benefited by a change to the mountains. The influ- 
ence of a tepid bath followed by a cool shower, or a cold bath in the morning, 
if the child can tolerate the same, is an excellent tonic. Such cool baths 
should be followed by friction of the skin to stimulate the cutaneous circula- 
tion. It is an excellent vasomotor stimulant. 



SCURVY. 301 

Some of these cases may require a mild faradic current of electricity 
applied over the stomach and intestines. By such treatment the plexus of 
nerves is easily stimulated to advantage. The electricity should be given 
for several minutes every other day, and if well tolerated may be given daily 
for a month or more. 

Scurvy (Scorbutus: Barlow's Disease). 

This is a constitutional disease resulting from improper feeding. 

Etiology. — It usually occurs before the end of the second year, and 
rarely occurs before the first six months of a child's life. As in adults, 
scurvy is found when fresh food has been withdrawn from the dietary. It 
is natural, therefore, to look for scorbutic cases among children who are : — 

First, deprived of breast-milk. 

Second, in those brought up exclusively on milk which is devitalized by 
'prolonged sterilization. 

Third, it is found in children brought up on condensed milk and on 
those proprietary foods to which fresh milk has not been added. There 
seems to be, therefore, a direct relationship between the absence of fresh 
milk, be it cows' milk or' human milk, and the development of this disease. 
It is a great mistake to attach importance to the fact that an infant was 
fed on a proprietary food unless we know whether or no fresh milk was 
added. It is the absence of the live factor in fresh milk which directly 
causes scurvy. 

Troup, of Christiana, quoted by Koettlitz, 1 is strongly of the opinion 
that scurvy is the result of a scorbutic element of the nature of a ptomaine 
present in the diet. Jackson and Vaughan Harley, 2 as a result of an 
experimental inquiry into scurvy, arrived at much the same conclusion. 
The question under discussion here is whether or not infantile scurvy is 
the result of the absence of some essential element in the diet or the pres- 
ence of some scorbutic factor. It is certain that an infant fed for a long 
period upon peptonized milk 3 will develop scurvy, but if potato gruel and 
raw meat juice are added, yet no other alteration made in the diet and no 
medicine given, the scurvy will rapidly disappear and the child be well 
in a few weeks. Thus the addition of a fresh element to the scurvy diet 
has cured the condition. Moreover, many of the diets, for example, oat- 
meal and water, upon which the young children become scorbutic, seem 
to exclude the possibilities of the development of ptomaines. The experi- 
ments of Jackson and Harley do not carry conviction that true scurvy 
has been produced in animals, but rather that a condition of ptomaine 
poisoning has resulted. It is possible that unsound food may hasten the 

; Guy's Hosp. Gazette, March 30, 1901. 

2 Proceedings Royal Society, March, 1900. 

3 The prolonged use of peptogenic milk powder will produce scorbutic 
manifestations. 



302 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

development of scurvy, but the evidence at present seems insufficient to 
invalidate the conclusion that infantile scurvy is due to the absence of 
an anti-scorbutic element rather than to the presence of some scorbutic 
poison. 

Summary of Essential Conditions. — The six essential conditions to be 
observed in the diet of infants are these : — 

1. The food must contain the different elements in the proportions 
which obtain in human milk, viz. : — 

Protein 1.5 per cent. 

Fat 3.5 per cent. 

Carbohydrate 6.5 per cent. 

Salts 0.2 per cent. 

Other constituents 0.6 per cent. 

Water 87.7 per oent. 

100.0 

2. It must possess the anti-scorbutic element. 

3. The total quantity in twenty-four hours must be such as to rep- 
resent the nutritive value of 1 to 3 pints of human milk, according to 
age, viz. : — 

Protein 225 to 675 grains. 

Fat 231 to 693 grains 

Carbohydrates 613 to 1839 grains 

4. It must not be purely vegetable, but must contain a large propor- 
tion of animal matter. 

5. It must be in a form suited to the physiological condition of the 
digestive function in infancy. 

6. It must be fresh and sound, free from all taint of sourness or 
decomposition. 

Pathology. — Haemorrhages in and around the joints and in the mus- 
cles are found post-mortem. The most important point, however, is the 
presence of subperiostial haemorrhage involving the long bones. Eotch 
states that the femora are the most commonly affected, and that there is 
a tendency to a separation of the epiphyses. Interstitial haemorrhage in- 
volving the lungs, spleen, kidneys, and interstitial glands has been found. 
When the kidneys are involved we can usually find haematuria. Haemor- 
rhages are frequently present in the mucous surfaces; thus the gums show 
a deep purple color, besides being swollen and presenting the character- 
istic spongy appearance. 

We are indebted to Barlow for his valuable studies regarding the 
pathology and symptomatology of this disease. The blood shows no specific 
changes which are pathognomonic to this disease. 



PLATE XI 




~. 



A M 







fflHIIR 



^M 





Infantile Scurvy. 1 Ellen S. Five years old. The gums are swollen 
or beefy and hanging in tumor-like masses. There are also blood- tumors on 
the forehead. (From the pathological laboratory of the Great Ormond Street 
Hospital. London. Courtesy of Sir Thomas Barlow.) 

l I am indebted to Dr. Richard Armstrong, of the Great Ormond Street Hospital, 
London, for valuable assistance in procuring Plates XIV and XV. 



PLATE XII 




Infantile Scurvy. Femur divided by anteroposterior section, showing 
the characteristic scorbutic changes ; including fracture of the shaft at about 
a quarter its length from the head, and displacement of the upper epiphysis. 
The especial feature is the wide separation of the periosteum from the upper 
half of the bone by new bone which has been organized from a pre-existing 
subperiosteal haemorrhage. 



SCURVY. 303 

Bacteriology. — ~No specific bacterium has as yet been found nor does 
the blood show any peculiarities bacteriological^. 

Symptoms and Diagnosis. — The symptoms are marked irritability by 
day and restlessness at night, associated with insomnia. The mother or 
nurse will usually say that the child cannot be satisfied and cries when- 
ever touched, most especially when the arms and legs are moved. It is 
very apparent that there is pain due to a swelling of the limbs, usually 
of the diaphyses just above the epiphyses. When not disturbed these 
children seem to lie quietly. Swelling of the limbs in the legs and fore- 
arm is usually present. While the skin over the swelling is tense there is 
no evidence of fluctuation. Tenderness on pressure is usually noted. 
Bluish-black spots, due to small subcutaneous haemorrhages, are visible. 
When haemorrhages affect the deeper parts around the eyes so that the eye 
itself will be pushed forward, a condition called proptosis will be noted. 
This condition of proptosis is found in advanced cases of scurvy. 

Owing to pain in the limbs the child does not appear to move, giving 
rise to the impression that the child is paralyzed. When this condition 
is seen in scurvy it has been called pseudo-paralysis. The gums are very 
spongy and swollen, and have bluish maculae over the surfaces. The child 
shows the evidences of marked anaemia and loss of weight. There is loss 
of appetite, and when food is taken the head perspires freely. The tem- 
perature rises in the evening to between 100° and 101° F. The pulse is 
small, feeble, and ranges between 120 and 140. The respirations are not 
affected. The clinical picture is one of marked malnutrition with symp- 
toms simulating tuberculosis. 

This disease is liable to occur in either sex; it is not influenced by 
climate or locality ; it is found as well in the best as in the poorest hygienic 
surroundings. By far the greatest number of cases is found among the 
rich. It is evident that this disease is due to improper feeding more than 
to an improper hygiene. Some authors believe that this disease is caused 
by a specific micro-organism; this latter fact has not yet been definitely 
settled. 

It is interesting to note the various views expressed by competent 
observers upon this subject; thus, while a large majority of clinicians 
hold that sterilized milk per se does cause scurvy, Botch states that it does 
not, in his own experience, seem to do so. Starr maintains just the reverse 
and believes that sterilized milk is a causative factor. From my own ex- 
perience I quite agree that sterilized milk — especially the prolonged ster- 
ilization, by which the albumins are changed, and by which this prolonged 
heating causes devitalization, which is so inimical to successful feeding — is 
a causative factor in this disease. 

It is peculiar that scurvy will be cured by giving raw milk, fresh 
fruits, and acid fruits; still we find that a great many clinicians per- 



304 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

sist in prescribing sterilized milk until either rickets or scurvy is estab- 
lished. It was for this reason that at a discussion on infant feeding at 
the Academy of Medicine, October 18, 1900, I was led to insist on the use 
of raw milk as the proper means of feeding children. 

Kaw milk possesses certain advantages over boiled milk; it is more 
readily assimilated, and the proteins are not so difficult to digest. It is a 
well-known fact that boiled milk and sterilized milk have a tendency to 
produce constipation, whereas the opposite is true of raw milk. 

Improper infant food has additional disadvantages when it is sub- 
jected to excessive heating. The large number of failures with milk modi- 
fied at a laboratory are not so much due to the process involved in the 
modification as to the amount of heat that the food is subjected to prior 
to being imbibed. 

Where milk is modified for infant feeding, using raw milk only, I 
have seldom seen constipation; the reverse, however, has always been true 
when milk was modified and then subjected to sterilization. The vital 
point has always impressed me as being, not so much to sterilize milk after 
it has been drawn from the cow, but to apply the principle of sterilization 
to the stable, the cow, the utensils, the milker's hands, and to everything 
coming into contact with the milk from the time it leaves the cow's udder 
until it is fed to the baby. 

When oatmeal gruel or barley gruel is given with an insufficient quan- 
tity of cows' milk and then fed for a long time, we must not be surprised 
ftp find a case of scurvy. When proprietary foods are given without the 
addition of fresh milk, then scurvy will usually result. When cream 
mixtures are given which are deficient in fat and proteins, then scurvy 
may result. Thus we find that the true, underlying cause of scurvy is 
starvation due to deficiency of one or more nutritive elements in the food 
given. 

The following cases of scurvy will illustrate the condition : — 

Case I. — Joe W., thirteen months old, was seen by me, in consultation with 
Dr. Samuel Barbash, at Atlantic City, October, 19 12. 1 The infant was bottle fed 
from birth. He was given condensed milk the first month and later, for a period of 
seven months, received Borden's malted milk. He was then put on cows' milk, which 
disagreed. The infant had mucous stools, which were streaked with blood. His 
general development was fair, although a bronzed condition of the skin existed. He 
had the first tooth when four months old, and was able to stand on his feet several 
weeks, until four weeks ago. It was then noted that he suddenly refused to stand, 
and that the slightest handling of the joints of his arms and legs produced severe 
pains. A diagnosis of articular rheumatism was made. 

There was marked tenderness over the joints. The head perspired freely when 
food was taken. The gums were soft and tender, and had a bluish-red ridge around 
the teeth. The weight at the age of thirteen months was 12 ^ pounds, which in 



* Case presented at the meeting of the Atlantic County Medical Society, October 
11, 1912. 



PLATE XIII 




Scurvy. Subperiosteal Haemorrhages. Infant nine months old. 
(Courtesy of Dr. A. George.) 



SCURVY. 305 

itself is sufficient to show faulty metabolism. There was a marked rachitic rosary, 
and beaded ribs on both sides, so that the diagnosis of scurvy and rickets was 
warranted. 

The sudden onset of symptoms made the case resemble a form of infantile 
paralysis: When the symptoms are associated with the bleeding gums, the purplish, 
spongy swellings, and the bluish-black, subcutaneous haemorrhages visible on the 
inside of the cheek, then the diagnosis of pseudo-paralysis associated with scorbutus 
must be made. 

Case II. — A child thirteen months old was brought to me with a history of being 
very restless and having lost considerable weight. The child showed a shriveled ap- 
pearance of the skin; its normal elasticity was gone; the skin was dry; the thorax 
was pigeon-breasted; the arms and legs were thin; both arms and legs showed marked 
tenderness on the slightest motion; there was baldness at the occiput, and the 
anterior fontanel was not closed; the child had eight teeth, all of which were slightly 
carious; the gums around the teeth were deeply congested and showed bluish ridges; 
the gums were spongy and bled very easily; there was an intense foetor to the 
breath; the child had been suffering from diarrhoea for the past two months, with 
occasional periods of constipation; there was no vomiting; the appetite had always 
been very poor. The previous history of the child was that, when born, it weighed 
about 5 pounds; it was very small at birth. The mother of the child died during 
confinement, and hence the baby was given into the care of a nursery. The diet 
consisted of 1 teaspoonful of condensed milk with 12 teaspoonfuls of water and a 
small pinch of sugar. This was fed every two hours for a period of over two months; 
later the child was put on barley water, to which some condensed milk was added. 
This was changed from time to time to a diet of oatmeal water and condensed milk. 

The child had always been frail, and had a cough and also an attack 
of acute capillary bronchitis; during the summer the child had a severe attack of 
cholera infantum, and almost lost its life from vomiting and purging. For one 
month this child subsided on a diet of oatmeal water, rice water, farina water, and 
albumin water, besides cold tea. Thus it is seen that the child received no milk for 
a period of over seven weeks. When the child was five months old it weighed 7 
pounds, and at this time it hardly weighs 10 pounds. There is a marked rachitic 
kyphosis; the ribs are beaded; there is a pendulous belly; the child has an umbilical 
hernia; the temperature, taken in the rectum at 2 p.m. for a period of at least 
two weeks, was no higher than 100° to 101° F.; there is an intense thirst; the 
kidneys are very active; the urine has a very high color; no hsematuria could be 
found. 

The diagnosis of infantile scurvy was made, and the child was put on the 
following treatment: Orange juice; lemonade; freshly expressed steak juice; raw 
milk, diluted with barley water or rice water, equal parts ( 4 ounces of milk, 4 ounces 
of barley water), repeated every three or four hours, depending upon the appetite. 
Massage of the body was very gently performed with codliver-oil or vaseline, to 
lubricate and to nourish. A 1-drop dose of nux vomica was ordered before each 
feeding. This treatment was given continually for three or four weeks. Every 
fourth or fifth day a half-ounce of barley water or rice water was withdrawn, and 
instead an equal quantity of fresh milk was added; hence, after four weeks of 
treatment this child received 6 ounces of milk with 2 ounces of barley water or rice 
water every four hours. 

The child was sent to the seashore, and after this treatment was continued for 
seven months all symptoms of scurvy had disappeared; the child recovered. 

20 



306 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

When children have walked, and suddenly stop walking, attention 
should be directed to the state of the gums and to the general physical 
condition. Such cases are usually suspicious, and may show the beginning 
of scurvy. Indeed, such symptoms will develop long before there is a 
general breaking-down. Emaciation and anorexia follow, which are asso- 
ciated in this condition. 

Differential Diagnosis. — From Rickets: This condition is easily dif- 
ferentiated. In scurvy there is no rachitic rosary. There are no haemor- 
rhages involving the gums nor spongy swellings found in rickets. The 
pendulous belly is not seen in scurvy, neither is the rachitic, square head. 

From Tuberculosis. — The" absence of cough and other physical signs in 
the lungs, besides the absence of the symptoms above mentioned common, 
to scurvy, will differentiate this condition from tuberculosis. 

Scurvy and Rickets. — Both diseases may be found at the same time 
in the child, and are evidently due to disturbances of metabolism founded 
upon dietetic errors in the absence of the live factors in food. 

Prognosis and Course. — The course of the disease is usually chronic. 
The outcome depends on the rapidity with which vitality can be restored. 
A decided change in the mode of living, the food, and the hygienic condi- 
tions must be continued for many months after improvement has been 
noted. Unless we persist with treatment relapses will occur. 

Treatment. — The most important part of the treatment of scurvy con- 
sists in eliminating the antiscorbutic elements by proper feeding. 

Dietetic Treatment. — Antiscorbutic diet consists of fresh milk, fine 
potato gruel, 1 raw meat, raw yolk of egg, orange juice,; and sugar. 

Fresh milk is clearly not a potent antiscorbutic, and, although suf- 
ficient to prevent scurvy when given in full quantity, will not always pre- 
vent it when taken in small amounts only. It fails accordingly to remove 
the scorbutic condition with quickness and certainty when given alone. 
It is necessary, therefore, to add to the food some more active agent, such 
as potatoes, carrots, or a vegetable juice, as orange juice, Malaga grapes, 
or a broth in which vegetables, such as carrots and potatoes, have been 
boiled and strained, with raw meat juice in addition. 

In addition to the rigid enforcement of the above-mentioned foods, 
we. must insist upon fresh air. 

Medicinal Treatment. — Eestoratives such as codliver oil, with. or with- 
out the hypophosphite of lime or soda; iron, arsenic, and strychnine are 
the most valuable in this condition. The lime salts are indicated; 3 to 5 
grains of calcium lactate may be given three times a day. Excellent results 



1 Prepared by rubbing thoroughly steamed floury potato through a fine sieve, 
and beating this up well with milk until it is smooth and of the consistency of thin 
cream. A teaspoonful of this may be added to each bottle at first, and the amount 
gradually increased to a dessertspoonful, if it is found to agree. Well-boiled carrots 
may be used in the same way. 



RACHITIS. 307 

can be obtained from the use of soluble forms of iron, such as peptomangan 
(Gude) or Fowler's solution, given after each meal. If a suspicion of a 
constitutional disorder such as syphilis exists, an alterative, like the syrup 
of the iodide of iron, 10 to 30 drops, or ferrosajodin tablets, % tablet three 
times a day, may be given. Malt extract contains a live factor, and is, 
therefore, valuable as an antiscorbutic restorative; it should be given in 
doses of a teaspoonful, two or three times a day, or until the bowels are 
loose, then the dose must be reduced. 

When recurring haemorrhages are noted, an injection of 10 to 15 cubic 
centimeters, or about 4 drachms, of sterile horse serum should be given. 
This will frequently be followed by a rapid disappearance of the bluish 
spots. 

Hygienic Treatment. — Besides having fresh air, a child suffering with 
scurvy must be put directly into the sun. This sun bath should be admin- 
istered daily, but, owing to the delicate nature of the skin, precautions must 
be used against scorching the same. Some children can stand no more than 
fifteen minutes' exposure to the sun's rays, while others will not scorch 
though exposed for an hour. Proper ventilation of the sleeping apartment 
is very important. A scorbutic child requires a daily bath consisting of 
one pound of sea salt to a tub of water at a temperature of 95° F. The 
child should be bathed from three to five minutes and rubbed briskly while 
in the tub. After the bath the body should be dried with a coarse towel 
and rubbed until the skin has a pinkish color. This friction or massage 
is very invigorating, and if done in the evening it will promote sleep and 
soothe the child. ^ 

Eachitis (Rickets). 

Rickets is a disorder of nutrition. It occurs chiefly between the ages 
of 6 months and 2 years. Congenital rickets is occasionally seen. It 
affects the bones primarily, and these are very readily distinguished during 
life. The disease also affects the ligaments, the mucous membrane, the 
muscles, and especially the nervous system. 

Pathology. — The lesions are chiefly noticed in the bones, although the 
soft tissues show evidences of anamiia. The primary lesion is hyper- 
emia of the periosteum, the marrow, the cartilage, and the bone. The 
spleen and liver are usually enlarged. Frequently we note enlargement of 
the lymphatic glands. 

Starck found the spleen enlarged in 50 per cent, of his autopsies in 
rachitic children, and in 68 per cent, of all his living cases. In the kid- 
neys there are usually no pathological lesions. The cartilage cells of the 
epiphyses undergo increased proliferation from four to ten times more 
than they do in a normal growing bone. The matrix is softer ; as a result 
the bone formed from this abnormal cartilage lacks firmness and rigidity. 



308 



DISORDERS RESULTING FROM IMPROPER NUTRITION. 



The increased proliferation of cells makes the epiphysis larger, swollen 
in appearance, irregular in outline, and much softer in consistence. It has 
been experimentally proven that hyperemia of bone causes defective de- 
compositions of lime salts. Owing to this deficiency of lime salts the bones 
become very soft and flexible. While normally there is two-thirds mineral 
matter in the bones, in rickets this is reduced to one-third. Thus we can 
easily explain the various "rachitic deformities" which are especially noted 



Fig. 84 



Figr. 




Cranial, Thoracic, and Abdominal Type of Rickets. 

Fig. 84. — Hydrencephaloid (Spurious Hydrocephalus). Infant 8 
months old. Bottle-fed. Suffering with cholera infantum^ Severe nervous 
and toxic symptoms. 

Fig. 85. — Same Child Two Years Later. Note the square head, the 
frontal protuberance. Also the Harrison groove and the pendulous belly. 
(Original.) 

in the femur, the tibia, the radius, the ulna, and the ribs. When ossifica- 
tion is retarded during rickets, as, for example, in the parietooccipital 
region, the bone is frequently so thin that it yields to pressure; this is 
called craniotabes. 

The fontanels are not closed until very late, owing to this delayed 
ossification. The frontal and parietal protuberances are very much en- 
larged, due to exaggerated proliferation of the periosteum, so that the 



K 

t-H 

H 

Hi 

Ah 




PLATE XT 




Rickets. Xote the flaring, cup-shaped, irregular termination of the diaphysis. 
Condition accounts for the enlargement of ankles in rickets. 



RACHITIS. 



309 






; 







■0-: 






.:-k 








&mm 



-^VX.; ; 



Fig. 86. — Rickets. Longitudinal section' through the ossification junc- 
tion of the upper diaphyseal end of the femur of a one-year-old child suffer- 
ing from rachitis of moderate degree, a, Unaltered hyaline cartilage, b, 
Cartilage in the first stage of proliferation, c, Zone of proliferated cartil- 
age cell columns, d, Columns of proliferated hypertrophic cells, e, vessels 
located in the cartilage, with fibrous marrow tissue, f, Decalcified cartilage 
tissue, g, Osteoid tissue, h, Remains of cartilage tissue in osteoid tissue. 
i, Trabecular of decalcified osteoid tissue. A:, Trabecular of osteoid and fully 
formed calcified bone tissue. I, Fibro-cellular marrow tissue. (Ziegler.) 



310 



DISORDERS RESULTING FROM IMPROPER NUTRITION. 



head acquires a broad forehead with characteristic frontal prominence. 
This condition is frequently taken for hydrocephalus. When ossification 
takes place the bones become large, heavy, and irregular in outline, corre- 
sponding to the clinical manifestations known as "bow-legs," "knock-knees," 
"pigeon-breast," "spinal curvature," and "square cranium." 

Where the bone joins the cartilage, as, for example, on the ribs, en- 
largements occur which simulate beads ; hence the term "beaded ribs," also 
called "rachitic rosary." The same enlargements can be felt at the wrists, 
ankles, and knees. 

A section through the epiphyseal junction of a rachitic bone shows a 
very vascular, bluish-colored condition, which is softer than normal when 




Fig. 87. — Spurious Hydrocephalus, Illustrating Marked Frontal and 
Parietal Protuberances. There was a striking resemblance to a case of 
hydrocephalus. Bottle-fed. Rachitic. (Original.) 

cut. In the shaft next to the periosteum the bone is soft and thickened, 
but deeper it is hard. Sections through thickened masses on the flat bones 
show a spongy, vascular substance which is soft enough to be indented 
easily. 

Microscopical examination shows a marked increase in new cartilage 
cells and increased vascularity of the proliferating zone. The areas which 
should be calcified show large quantities of cartilaginous tissue instead. 
The under-layer of the periosteum is very vascular, and again there is a 
great excess of uncalcified cartilage. In the flat bones the bony trabecule 
are eroded, and their places taken by newly formed minute blood-vessels. 

When the rachitic process ceases and recovery begins, this excessive 
proliferation stops. Calcification and ossification of these tissues take 



RACHITIS. 311 

place; the enlargements due to the hyperplasia are absorbed, and the bone 
returns to a normal condition save for any deformities that may have re- 
sulted during the activity of the rachitic process. 

Etiology. — Children that have suffered prolonged diarrhoeas or with 
severe diseases — like dysentery, typhoid, bronchitis, and pneumonia — are 
prone to the development of rickets. Children of syphilitic parents and 
those whose parents are tuberculous are more prone to the development of 
this .disease. Von Ritter, quoted by Professor Saginsky, says that, in 27 
cases out of 71 examined by him, rickets was not only found in the 
children, but as well in the mothers of these same cases. Thus it is that 
Kassowitz and Schwarz 1 have mentioned the existence of congenital rickets. 
These same authors found that 80 per cent, of children born in the Vienna 
Lying-in Hospital were rachitic. This statement is not so easily accepted, 
for neither Professor Baginsky nor Virchow accept the same. Experi- 
mentally, it has been found as long ago as 1842 by Chossat that when 
lime is deducted from the nourishment of young animals not only soft 
bones result, but they finally die. Heitzmann maintains that, if lactic 
acid is introduced into the food of young animals, the result will be, first, 
rickets, and, later on, osteomalacia will result therefrom. Clinical investi- 
gations have shown that cases of rickets occur more often during the winter 
months; thus it would seem that improper hygiene is one of the factors 
causing this disease. 

The bones show the most characteristic result of .improper nutrition, 
for they are very soft and spongy. They will yield to the weight of the 
body if used in walking, and thus it is that bow-legs with extensive curva- 
tures form such a prominent feature in showing the result of using "soft 
bones. 

The absence of human milk from the diet of an infant is one of the 
prime reasons for the development of rickets. We therefore find more than 
90 per cent, of all cases of rickets among bottle-fed babies. Other 
contributing factors are the absence of sunshine and the crowding of 
large families into small rooms having poor ventilation. Pickets will 
occasionally be seen in the breast-fed child under similar conditions. If the 
mother while nursing suffers with malnutrition, malaria, chronic cough, 
or with any organic lesion which devitalizes her body, then poor breast- 
milk deficient in its nutritive elements will cause the baby to be underfed 
and finally result in rickets. 

Symptoms.; — One of the earliest symptoms noted is constipation. Head 
sweating while feeding, especially at night, is an early symptom of rickets. 
Polling of the head on the pillow, with occipital baldness, pallor of the skin, 
and profound anaemia, frequently precede or accompany the development 
of rickets. Pachitic changes affect the fontanel and the sutures, as well as 



Wiener medicinische Jahrbucher, 1887, vol. viii. 



312 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

all the bones of the cranium. The rhombic form assumes an irregular out- 
line. The sutures, especially the lambdoidal and frontal, are distended. 

The fontanel remains open much longer than in normal infants, so 
that not infrequently the anterior fontanel can still be felt slightly open 
as late as the third or fourth year of life. Although the usual type of 
rachitic head is square, not infrequently it assumes an asymmetrical form. 

We are indebted to Elsasser for a description of one of the most valu- 
able symptoms in rickets, namely, "softening of the cranial bones," known 
as "craniotabes." Small areas of softened bone which will yield on the 
slightest pressure can be felt in the region of the lambdoidal suture. 

Early symptoms of rickets also are tetanic seizures, muscular spasms, 
and laryngeal spasms. Dentition is delayed, the teeth appearing irregu- 




Fig. 88. — Rachitic Ribs. Incurvation of the ribs at the osseous-cartilaginous 
junction in rickets. One-half natural size. ( Langerhans. ) 

larly, and in older children they are carious. Not infrequently we find 
no evidence of teeth until the child is 16 or 18 months old. Eachitic symp- 
toms appear later in the thorax than in the head, although they can be 
plainly made out during the first six months. Beaded ribs are especially 
prominent in advanced cases. There is a marked depression of the thorax 
in a line parallel with and on either side of the sternum. This line cor- 
responds with the course of the beads. The so-called pigeon-breast or 
funnel-breast (pectus carinatum) is frequently observed in rickets. 

The veins of the scalp are usually enlarged. Spinal rickets is espe- 
cially characteristic. The posterior curve of the spine is commonly known 
as rachitic kyphosis. It extends from the middle-dorsal to the sacral 
region. 

This kyphosis has been found in more than one-half of my cases. The 
curve can be lessened or it will disappear when the child is placed on its 
back and extension is made on the extremities. The more important 
rachitic deformities are: — 



RACHITIS. 



313 




Fig. 89. 



Fig. 90. 




Fig. 91. Fig. 92. 

Illustrating Rachitic Erosions of the Permanent Teeth. 1 



l I am indebted to Dr. Hugo Neumann, Privat-dozent in Berlin, for the above 
illustrations. 



314 



DISORDERS RESULTING FROM IMPROPER NUTRITION. 



1. Bachitic kyphosis. 



Bachitic scoliosis. 
Chicken (or pigeon) breast. 
The rachitic pelvis. 
Cubitus valgus or varus. 
Distortion of the lower extremities :- 
(a) Genu varum. 



Fig. 94 



Fig. 93 





Fig. 93. — Five-week-old Fracture of the Humerus, in a Rachitic Child 
1% years old. ( Langerhans. ) 

Fig. 94. — A severe Type of Rickets With Enlargement of Both 
Condyles of the Femur. There is also enlargement of the upper epiphyses 
of the tibia and fibula. The illustration also shows enlargement of the 
epiphyses of the ankles. An anteroposterior curvature (giving the bow-leg 
appearance) is plainly seen. Note also the enlarged epiphyses of the radius 
and ulna. Drawn from a photograph. (Original.) 

(b) Genu valgum. 

(c) Anterior curvature of the tibise. 

(d) General distortions of the lower limbs. 



RACHITIS. 



315 



Diastasis of the Recti Muscles in Rickets. — When the muscles lose their 
tone, we frequently have the bony changes soon afterward. Diastasis of the 
recti muscles of one-half or one inch can sometimes be made out. To prop- 
erly examine a child for this condition it should be laid on its back with the 
head and shoulders elevated ; thus the recti muscles will relax and a pro- 
trusion of the abdominal contents in the median line can be noted. 




Fig. 95. — Case of Rickets Showing Enlarged Spleen; also Pendulous 
Belly. (Original.) 



The clavicle is affected only in severe cases. 

Extremities. — It is not difficult to note deformities in the humerus. 
The epiphyses, as in all long bones, are thickened and enlarged. The 
thickening of the epiphyses in the radius and ulna is readily made out. 
The shafts of these bones describe a convexity upon their extensor surface. 
Green-stick fractures are very common in these bones. The ends of the 
metacarpal or of the phalanges are sometimes enlarged. 



316 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

The Lower Extremities. — The outward bend of the tibia and, in marked 
cases, of the femur produce the condition known as bow-legs (genu varum). 
(Fig. 94.) In these cases when the feet are put together the knees are far 
apart. The opposite condition known as knock-knee (genu valgum) may 
exist. The inner condyles of the femur are hypertrophied, so that when 
the knees are put together the feet are far apart. Knock-knees are more 
common in females. The ligaments around the joints are relaxed and 
weakened, so that from an anatomical standpoint they assist in producing 
this deformity. The muscles show marked evidences of this disease. They 
are flabby, soft, and small with poor development. This accounts for the 
lateness in walking. The muscular power is very feeble, and not infre- 
quently paralysis will be suspected when really we are dealing with ag- 
gravated rachitic muscles. 

Malnutrition is plainly made out on studying those emaciated, anaemic 
children whose bones are markedly rachitic. On the other hand, we fre- 
quently find very fat children with extreme pallor showing marked rickets. 
Therefore, a fat infant is not necessarily a healthy infant. The abdomen 
is enlarged and usually tympanitic on percussion. It is commonly known 
as the "pendulous belly." This latter symptom I met with in fully 90 
per cent, of my cases in a large children's service extending over many 
thousand cases. I have rarely failed to note the distended belly in rickets. 
The loss of tone in the abdominal muscles, and especially in the muscular 
walls of the stomach and intestines, is one of the prime reasons for con- 
stipation. Occasionally the reverse may be true and diarrhoea may be 
noted. . There is frequently, marked distention of the stomach and colon. 
The stools are hard and dry, causing a chronic catarrh of the colon. We 
frequently find at the end of the stool a large amount of glairy mucus. 

The pulse and temperature are normal. Occasionally a bruit can be 
heard over the anterior fontanel. It has no special significance. There 
is nothing characteristic in the urine in rickets. The blood has been 
studied by Morse, who concludes that anaemia is present in most cases. 
Its intensity varies with the intensity of the rachitic process. Leucocytosis 
may or may not be present. An enlarged spleen is met with in these cases. 

Convulsions and -, spasms of various descriptions occur frequently in 
rickets. There seems to be a predisposition to general tetany, and to laryn- 
geal spasm (spasmophilia). The general weakness of the body is also 
seen in the marked tendency to irritation in the nerve centers. Most 
diseases in rachitic children are ushered in with convulsions, thus showing 
the extreme sensitiveness and susceptibility of the nerve centers. An 
overloaded stomach in a rachitic child under 1 year of age, suffering with 
high fever, is usually attended with hyperpyrexia and convulsions. 

Diagnosis. — This is usually very easy. Head sweating, constipation, 
restless at night, delayed dentition without palpable osseous manifesta- 



RACHITIS. 317 

tions usually mean rickets. The most prominent symptoms are beaded 
ribs, enlargement of the epiphyses of the wrists and ankles, kyphosis of 
the spine, and bow-legs. 

Differential Diagnosis. — The rachitic head is sometimes mistaken for 
hydrocephalus. The electrical reaction will decide whether or no we are 
dealing with a poliomyelitis, or if the ease is a pseudo-paralysis with 
rickets. We can differentiate the bony enlargements of syphilis from rickets 
with the aid of an x-ray. The tony changes in syphilis affect the shaft 
of the bone rather than the extremities. An important point to remember 
is that in syphilis there may be necrosis ; this is never seen in rickets. The 
differential diagnosis will best be made by a blood examination for the 
presence of a Wassermann reaction. Scurvy is easily differentiated from 




Fig. 96. — Rickets, Showing Beaded Ribs and an Enlarged Pendulous 
Belly. Mouth-breathing due to adenoids. Breast-fed infant. Always lived 
in tenement house district. Mother very anaemic. (Original.) 

rickets by the spongy condition of the gums, by the tendency to hsemor- 
rhage, and usually also by the presence of ecchymotic spots. The diag- 
nosis of rachitic kyphosis from spinal tuberculosis • (Pott's disease) is 
easily made, although I have seen one case in which there existed a rachitic 
kyphosis in a tuberculous child. 

Prognosis and Course. — Rickets, per se, is rarely fatal. The active 
symptoms exist about one or two 3 r ears; in rare instances for many years. 
Damage of the system may remain throughout life. Spinal curvatures and 
thoracic deformities will remain for many years. 

Rachitic children when attacked by infectious diseases suffer far more 
and the prognosis is graver than it would be otherwise. The abnormal 
condition of the thorax in rachitic children must always be taken into 
consideration in a child suffering with pneumonia, pleurisy, or other pul- 
monary conditions, in estimating the outcome of the disease. 



318 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

Treatment.— Hygienic Treatment: When rachitic conditions are estab- 
lished the first thing to do is to insist upon removing such children to 
healthful surroundings. When children are housed in poorly ventilated 
homes, dark rooms, it is useless to give medicine until the unsanitary sur- 
roundings are improved. Successful treatment in such cases demands plenty 
of sunshine, open windows, night and day, a tub bath with a handful of sea 
salt added every day. After the bath good brisk rubbing to stimulate the 
circulation is very necessary. A change of air from the city to the country 
is desirable. When we are prescribing for the poor they should be instructed 
to remain in the park as much as possible. The establishment of small roof 
gardens on the tops of the highest dwelling or tenement houses makes a 
cheerful place for the rachitic children to play. 




Fig. 97. — Rickets. Note Beaded Ribs on Left Side of Thorax. (Original.) 

Dietetic Treatment. — -Next to hygienic methods the care of the diet 
is important. If a nursing infant shows rachitic symptoms the chemical 
examination of the breast-milk should be made. If we find low proteins 
the nursing mother or wet-nurse should be given more meat, eggs, and 
cereals. If, however, conditions exist which prevent proper nursing, the 
child should be weaned. A properly modified cows' milk adapted for the 
age and development (see section on "Nutrition") should be substituted. 
I insist on feeding such children with cereals, such as barley, rice, cream of 
wheat, sago, farina, etc., and giving them plenty of fresh vegetables, such as 
spinach, asparagus, peas, and beans. Eggs, white meats, and fish may be 
given if children are old enough. Fresh fruits must not be forgotten. 
Butter and cream are valuable adjuncts to the dietary. 

Medicinal Treatment. — In addition to the importance of proper feed- 
ing we must seek to establish proper metabolism. All the emunctories 
must be carefully watched. Drug, treatment should be directed to supply- 
ing the deficient amount of lime in the bones. The glycerophosphate of 



RACHITIS. 



319 



1 ime, which has been used by me for several years, in doses of 1 to 5 grains, 
three times a day, is very useful. Codliver-oil, to which V 200 grain of 
phosphorus is added, has served me very well in some instances. This 
phosphorized codliver-oil must be freshly prepared, as it deteriorates on 
standing. Hundreds of children in the crowded sections of the city have 
been put on the phosphor treatment. When codliver-oil was added to the 
phosphor, good results were noted, not otherwise; so that I believe it is the 
codliver-oil rather than the phosphor that possesses medicinal virtues. 




Fig. 

Fig. 98. — Rachitic Kyphosis (Spine). Permanent deformity. Rachitic 
thorax in school girl, 12 years old, showing Harrison's groove, and funnel- 
shaped depression of sternum. 

Fig. 99. — Back View Same Child, Showing Rachitic Kyphosis. This 
deformity is the permanent result of rickets in infancy. It is to be differ- 
entiated from Pott's disease. Note also the curvature of the spine. 
(Original.) 

Fellow's syrup of hypophosphites, arsenic, iron, and strychnine have served 
me very well, especially when atony of the stomach or dyspeptic conditions 
existed. The careful regulation of the bowels and good action on the part 
of the kidneys and skin will greatly aid in modifying rickets when 
established. 

Treatment of Deformities. — Kyphosis: In rachitic kyphosis a Brad- 
ford frame or a similar appliance is indicated. A spinal brace will some- 
times do good. Massage with good friction will develop a weakened spine 



320 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

in some cases, and plaster of Paris jackets may be serviceable. Manual 
correction of the deformity will aid in the treatment. 

History of Rickets in Infancy.- — A very anaemic, poorly developed girl. Brought 
up in a tenement house in the thickly crowded portion of New York City. Was 
breast-fed during infancy, fifteen months. Had summer complaint. Dentition began 
at eight months, walking at sixteen months. Very bright mentally. Is very 
restless at night; nervous, choreic twitching during the day. No mammary develop- 
ment, no evidence of menstruation. 

Father and mother of this child are apparently well, though dyspeptic. No 
evidence of syphilis or tubercular disease. This child has had tonsillar infections 
several times each year; had diphtheria, measles, and scarlet fever. Has diarrhoea 
whenever nervous or frightened. 

Since instituting gymnastic exercises, the muscles of the back have been 
greatly strengthened, although the spinal deformity has not been lessened or 
improved. 

The -main treatment consisted in fresh air, out-of-door exercise, diet of milk, 
cream, butter, fruits, cereals, and meats. Stop school and all studies. 

Medication, codliver-oil, malt, glycerophosphate of lime and soda, raw egg?,. 
Cool sponging with sea salt. Friction of body after gymnastic movements. 

Scoliosis (Lateral Curvature) and Lordosis (Forward Curvature of 
the Spine). — The management of these conditions is similar to that de- 
scribed for kyphosis. 

Cubitus, Varus, and Valgus. — These deformities disappear as a rule 
without special treatment. 

Bow-legs (Genu Varum). — This common rachitic distortion may be 
congenital or it may be an acquired condition. The treatment consists in 
support and correction by braces. 

Whitman believes that correction by osteotomy or osteoclasis is neces- 
sary when children are over 5 years of age. For knock-knees braces are 
usually necessary. The Thomas knock-knee brace is the most efficient. In 
some cases osteotomy of the femur just above the epiphyseal line is indi- 
cated. 

Antero-posterior bow-leg can only be corrected by osteotomy. 

Genu Recurvatum (Back-knee) . — Whitman states that in its most 
extreme form it is of congenital origin, and is usually associated with 
defective development of the anterior thigh muscles and of the patella. 
In such cases the knee is bent directly backward, and the tibia is often dis- 
placed forward upon the femur. In the milder types of back-knee there 
is simply an abnormal or over-extension caused by laxity of the ligaments 
and supporting muscles. This form is usually secondary. It is often seen 
in cases of hip disease after prolonged mechanical treatment. It may be 
associated with congenital talipes, or it may be the direct result of paral- 
ysis of the muscles of the legs, or even of general weakness, as in severe 
rachitis. 

The following are the principal points in the differential diagnosis of 
rickets and Pott's disease : — 



DECOMPOSITION. 321 

Table No. 38. 
Rickets. Pott's Disease. 

Deformity not angular. Angular. 

Result of posture. Result of lesion. 

Evidences of rickets elsewhere. Absent. 

In infancy. Usually later. 

In middle and lower part of the spine. In any part. 

The body may be bent forward with- Forward flexion causes pain, 
out discomfort. 

The curve is lessened, or it may be Never disappears, 
obliterated when the trunk is ex- 
tended. 

Surgical Treatment. — It is always safe advice to consult a surgeon or 
orthopaedist concerning deformities in early life. Very many rachitic de- 
formities due to softened diaphyses can be corrected or modified as de- 
scribed in the treatment previously given. When a brace appears unsatis- 
factory, then surgery may yield excellent service, but surgery must be used 
in conjunction with proper nutrition and restorative treatment to secure 
permanent benefit. 

Decomposition (Infantile Atrophy; Marasmus, or 
Wasting Disease). 

If the symptoms of dyspepsia are prolonged there is a marked decrease 
in weight. In addition thereto there is a marked disturbance of the 
thermic center, and the previous febrile temperature gives place to a sub- 
normal temperature. The pulse is slow, the respiration irregular, and the 
food tolerance is greatly reduced. The gravity of this condition must be 
apparent because of the constant loss of weight. 

The condition is met with as a result of malassimilation of food. It is 
really a deficient metabolism, and results in a gradual decline. It is impor- 
tant to note that constitutional disorders, such as tuberculosis or syphilis, 
are not the causative factors. A von Pirquet test should be made to 
differentiate this condition from tuberculosis. 

Etiology. — The condition is caused by improper feeding, such as to fre- 
quent feeding of high-fat formulae. By far the greater number of cases of 
atrophy are found in bottle-fed infants. An occasional case may occur as 
the result of faulty human-milk feeding. If we meet with a case of atrophy 
in a breast-fed infant, the thing to do is to have a chemical examination 
made of the breast-milk. If it is found deficient in quality, we must with- 
draw it and substitute bottle-feeding. If we wish to discard the mother's 
milk for some reason, it is advisable to secure a wet-nurse. The removal 
of such cases from the breast to the bottle or from the bottle to the 
human breast may be necessary to save life. 

21 



322 



DISORDERS RESULTING FROM IMPROPER NUTRITION. 



The true pathology seems to be a failure to assimilate food in infants 
with improper hygiene, and as a result progressive emaciation takes place. 

Symptoms. — When infants surfer with vomiting or diarrhoea, and this 
condition is allowed to become chronic, then colic and flatulence, associated 
with constipation, supervene, and the result as a gastrointestinal catarrh. 
Neglect of this condition means the development of the condition known 
as atrophy. The infant does not thrive, commences to waste, and unless 
we realize the condition, and give the proper treatment, the infant will die 




Fig. 100. — Decomposition. The loss of fat causes the skin to hang 
in loose folds. Note the left forearm and both legs. The forehead is 
wrinkled. The hand in the mouth is a characteristic symptom of starvation. 
(Original.) 



from exhaustion and inanition. When these cases linger for months they 
develop rickets. Eecovery without treatment is impossible. 

Prognosis and Course. — The course of this condition depends on the 
amount of nutrition that can be assimilated. The worst forms of marasmic 
infants will frequently gain in weight when proper food is given. If the 
appetite is poor a decided change of air, from the city to the country, or 
vice versa, will strengthen the infant and restore the appetite. Many an 
infant's life has been saved by a trip to the seashore or a sea voyage. The 
outcome of the case depends on judicious feeding, a change of air, and 
proper hygienic management. 



DECOMPOSITION. 323 

Treatment. — If high-fat formulae have caused this condition, the treat- 
ment consists in lowering the fat percentage of the food. Such cases will 
do well on skimmed milk. When skimmed milk is given, no sugar should 
be added. It is difficult to lay all blame on the cream, top-milk, or high-fat 
formulae, especially if sugar has been added. In some cases omitting the 
sugar from the food will be sufficient ; other cases require that both fat and 
sugar be discontinued for a number of weeks or until a tolerance for a small 
amount of fat and sugar has been established. 

It is in this class of cases that the albumin milk or eiweiss milch of 
Finkelstein renders such good service. By feeding 6 to 8 ounces of this 
food every four hours for several weeks, the foetid odor of the stools will 
disappear and they will gradually assume normal conditions. During suc- 




Fig. 101. — Infantile Atrophy. The emaciation is seen on the neck, 
right arm, the thighs, and legs. The tendons on the right foot are plainly 
seen. (Original.) 

cessful treatment with albumin milk we must not expect a gain in weight. 
As long as the fat and especially sugar is withheld we cannot expect a gain 
in weight. 

Albumin milk is prepared as follows: A tablespoonful of Simon's 
essence of rennet (or 2 tablets of rennet) is added to 1 quart of milk, which 
is then placed in a water-bath of 107° F. for one-half hour. It is then 
filtered slowly by gravity without any pressure for about one hour through 
cheesecloth. The coagulum is then washed twice in 1 pint of water through 
a very fine sieve and forced through by means of a wooden spoon; then 1 
pint of buttermilk is added. The chemical analysis of the food shows : — 

Albumin Milk Coics' Milk 

Protein 3.00 3.00 

Fats 2.50 3.50 

Carbohydrates 1.50 4.50 

Ash 0.50 0.70 



324 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

The theory as to the difficult digestibility of cows' milk casein is a 
thing of the past. Casein, as first shown by the teachings of the Breslau 
school, is readily digested, even by infants with serious digestive disorders. 

I'he whey experiments have proven that the milk sugar in correlation 
with the whey salts are the primary disturbing factors, the ensuing abnormal 
milk-sugar fermentation causing faulty fat digestion. 

The high percentage of casein, in correlation with the reduced whey 
salts and milk-sugar, counteracts the fermentative processes in the intestinal 
canal. Furthermore, it allows the feeding of a comparatively high percent- 
age of fat. The carbohydrates should be increased by gradual addition of 
dextrimaltose. 



PART V. 

DISEASES OP THE HEART, LIVER, SPLEEN, PANCREAS, 
PERITONEUM, AND GENITO-URINARY TRACT. 



CHAPTER I. 
INTRODUCTORY. 

The Heart and Fcetal Circulation. 

The circulation of the blood during the whole foetal period of ante- 
natal life is the same. From the third to the tenth month the circulation 
is known as "placental," and during the intervening months it undergoes 
no marked modifications. 

According to Ballantyne, 1 during the neo-fcetal period, it is true the 
circulation is that of the chorion; but by the end of it there has been a 
specialization of the circulatory function, and the blood, instead of being 
sent to the villi over a wide expanse of chorionic surface, is now directed 
solely to those found over one part of it, that, namely, which is in contact 
with the decidua serotina, the site of the developing placenta. From the 
end of the neo-fcetal period onward to the moment of birth, there is the 
circulation of the placenta. 

The essential peculiarity of the placental circulation is the sending of 
the foetal blood out of the foetal body to a specially prepared and extra- 
corporeal organ (the placenta) for purposes of oxygenation and other less 
understood chemical changes. This entails simply the presence of an 
efferent vessel (or vessels) to carry the blood to the extra-corporeal organ 
and of an afferent vessel to bring it back again. 

Changes at Birth. — When the umbilical cord is ligated there is an 
interruption of the circulation through the umbilical vein and arteries, so 
that in about ten days after birth the circulation loses its foetal type and 
assumes extra-uterine conditions. 

The following physiological changes occur : — 

(a) The conversion of the ductus arteriosus. 

(b) The ductus venosus into fibrous cords. 

(c) The closure of the foramen ovale. 

(d) Changes in the umbilical veins and umbilical arteries, the first 
forming the round ligament of the liver, the second the true anterior liga- 
ment of the bladder and the superior vesical arteries. 



1 For those interested I would advise reading Ballantyne's book on ante-natal 
pathology and hygiene. 

(325) 



326 



THE HEART AND FCETAL CIRCULATION. 



For some weeks before birth the circulation through the foramen ovale 
is slight, it being gradually obstructed by the growth of a septum which 
nearly fills the space at birth. After the first week of extra-uterine life, 
very little if any blood passes through it, although complete closure of the 
foramen often does not take place until the middle of the first year. In 
one-fourth of the autopsies Holt made upon infants under six months of 
age, minute openings at the margin of the foramen ovale were found. They 
were usually oblique, and closed by the valvular curtain so as to effectually 
obstruct the current of blood. The ductus arteriosus is first closed by a 
clot, which becomes organized and blends with the products of a proliferat- 




Fig. 102 



Fig. 103 



Fig. 104 



Fig. 102. — Note the Position of the Apex Beat in a Very Young 
Infant; during the first year it is very high, between the fourth and fifth 
intercostal spaces. It is most often in the fourth. 

Fig. 103.— The Apex Beat in a Child About 6 Years "Old. It is lower 
than in an infant. Usually found at the fifth intercostal space. 

Fig. 104. — The Apex Beat in a Child About 12 Years of Age is found 
between the fifth and sixth intercostal space. 

The heavy black lines denote the area of relative dullness. The small 
shaded areas denote the area of absolute dullness. (After Unger.) 

ing arteritis. It is rarely found open after the tenth day, and by the 
twentieth it is almost invariably obliterated. 



The Heart. 1 

Size of the Heart. — The relative size of the heart is greater in children 
than in later life. It is smallest about the seventh year. 

Table No. 39. — Weight of the Heart {Boyd). 
Age Grams. 

At birth 20.6 

One and one-half years 44.5 

Three years 60.2 

Five and one-half years 72.8 

Ten and one-half years 122.6 

Seventeen years 233.7 

1 Heart murmurs are described on page 330. 



THE HEART. 327 

The anatomical differences in the child are : — 

(a) A more horizontal position of the heart than in the adult. 

(&) The diaphragm being higher, the heart is higher in the thorax. 

(c) The ribs in a child are more horizontal than in the adult. 

(d) The liver in young children is larger than in adults, and as the 
heart is in close contact with the liver the area of cardiac dullness merges 
into that of the liver dullness below. 

Tension. — The degree of contraction of the vascular muscles deter- 
mines the size of the artery and (to a great extent) the tension of the 
blood within it. But if the heart is acting feebly there may be so little 
blood in the arteries that even when tightly contracted they do not subject 
the blood within them to any considerable degree of tension. "To produce 
high tension, then, we need two factors: a certain degree of power in the 
heart-muscles, and contracted arteries. To produce low tension we need 
only relaxation of the arteries, and the heart may be either strong or weak. 

"The pulse of low tension^ collapses between beats, so that the artery is 
less palpable than usual or cannot be felt at all. Xormally, the artery can 
just be made out between beats, and any considerable lowering of arterial 
tension makes it altogether impalpable except during the period of the 
primary wave and of the dicrotic wave, which is often very well marked 
in pulses of low tension." 

"The pulse of high tension is perceptible between beats as a distinct cord 
which can be rolled between the fingers, like one of the tendons of the 
wrist. It is also difficult to compress in most cases, but this may depend 
rather on the heart's power than on the degree of vascular tension. The 
pulse wave is usually of moderate height or low, and falls away slowly with 
little or no dicrotic wave. 

Fig. 105. — Irregular Pulse, Low Tension, from a Case of Mitral 
Regurgitation. ( Original. ) 

Mode of Examination of the Heart. — The ear should be used, rather 
than an instrument in listening to the heart sounds in struggling children. 
In children with eruptive fevers it is safer to use a phenendoscope. For 
this purpose the Bowles phenendoscope (Fig. 106) is highly recom- 
mended, as it has a flat attachment which can conveniently be placed in 
the axilla or to the posterior portion of the lung without raising the child 
from the bed. These advantages are important inasmuch as we frequently 
can examine the child while asleep. 



328 



THE HEART AND FCETAL CIRCULATION. 



The following aphorisms are drawn from Crandall : 

1. The apex lies higher in the chest and further to the left than in 
the adult. 




Fig. 106.— Natural Size of Bowles Stethoscope for Examining Children. 

2. The apex beat is hard to detect in the infant. In the child palpa- 
tion shows this easier than in the adult. 

3. The area of dullness is comparatively large. (There are three 
stages in infancy and childhood during which differences are noted in rela- 
tive and absolute dullness.) (See Figs. 102, 103, and 104.) 




Fig. 107. — A Convenient Stethoscope for Children. Made by Gk Tiemann 
& Co. and by George Ermold. New York City. 



4. Murmurs are heard over comparatively large areas. A study of 
differences in the quality of the sounds and points of greatest intensity will 
help us here. 

5. The rate may be increased and the rhythm altered by slight causes. 

6. In rachitic children and in those affected by empyema or pleural 
effusions and adhesions the apex may appear in an abnormal position. 

7. Prominence of the precordia is sometimes marked. Normally the 
loudest sound is the first sound at the apex; the weakest sound is the 
second sound at the aortic cartilage. This accords with my experience, 



THE HEART. 



329 



though it does not seem to be generally recognized that the pulmonic second 
sound is in early life stronger than the aortic sound. 

Table No. 40 — Classification of Cardiac Diseases. 



Time of 
Occurrence 



Intra-uterine 

existence 

or very 

early infancy. 



Extra-uterine 

existence 

(infancy or 

childhood) . 



Nature of the Affection 



{Developmental 
or 
Inflammatory. 

Various motor or sensory 
phenomena unaccom- 
panied by sensible 
changes of structure. 



Organic, 



r Mechanical. 



I Inflammatory. 



Miscellaneous. 



Clinical Disease. 



Various congenital affections. 



1 

[ Functional diseases of the heart. 



J 

f Dilatation, 

( Hypertrophy, 



Alone or as accom- 
paniment of in- 
flammatory change. 



(Pericarditis, acute or chronic. 
Endocarditis, acute or chronic. 
Myocarditis, acute or chronic. 

{Effusions (non-inflammatory). 
Granulomata. 
Neoplasms. 



CHAPTEE II. 
DISEASES OF THE HEART. 

Keflex Symptoms of the Heart. 

Tachycardia. — Severe palpitation of the heart (tachycardia) fre- 
quently results from excitement or fright in children. The heart on aus- 
cultation will be found normal, and the only symptom noticeable will be 
an exaggerated pulse-rate with an increase of twenty to forty beats per 
minute. It is usually a neurotic manifestation. As a rule the prognosis 
is good. The treatment consists in removing the cause if possible. 

Bradycardia. — A slowness of the heart's action and a slow pulse-rate 
are occasionally met with in children. It may occur in health, although very 
rarely without pathological significance. I have usually seen bradycardia in 
septic cases of diphtheria at my service in the Willard Parker Hospital, and 
in the septic type of scarlet fever at the Eiverside Hospital. • When brady- 
cardia is seen during the course of acute infectious diseases it should be 
regarded as a very serious symptom (see chapter on "Diphtheria"). 

Points to be Noted in the Diagnosis of Diseases of the Heart. 

Heart Sounds and Murmurs. 

First Sound. — In infectious fevers there is an increase in the length 
and intensity of the first sound heard at the apex. 

In continued fevers causing degeneration of the heart muscles there 
is a shortening and weakening of the first sound heard at the apex. 

In exhaustive heart strain seen in myocarditis the first sound is feeble 
and merges into the second sound. This condition is met with in diph- 
theria, scarlet fever, and typhoid, although any disorder of the body which 
devitalizes may cause it. 

Fatty heart, emphysema, or pericardial effusion may give a feeble mitral 
first sound. 

Pulsus Paradoxus. — The heart-beats during inspiration are more fre- 
quent, but less full, than during expiration. This condition may be observed 
in healthy children during sleep. 

An irregular heart's action may occur during sleep in healthy children. 
The heart's action is frequently influenced by inspiration and expiration. 

Systolic Murmurs. — There are two murmurs possible for each orifice, 
or eight in all. Of these, four, namely, mitral systolic, mitral presystolic, 
(330) 



MURMURS. 331 

aortic systolic, and aortic diastolic, are most likely to occur, with a fre- 
quency about in the order of their enumeration. The necessary changes 
being made, a like distribution applies to the right side; although a pul- 
monary lesion is almost unknown, except as a congenital affection, while 
disease of the tricuspid valve is less rare. 

Every murmur is determined by the time of its occurrence, the direc- 
tion which it takes, and the location of its greatest intensity. The blood 
is driven from the left ventricle, during systole, through the aortic orifice, 
and, meanwhile, all communication with the auricle of this side is cut off 
by a closure of the mitral valve. But should the current encounter an 
obstacle at the aortic opening in its onward course, it would be thrown into 
confusion in the aorta, from which a murmur would arise and be carried 
upward. Hence this bruit is loudest at the aortic area, systolic in rhythm, 
and extends in the direction of the carotids. 

Should the mitral valve fail to close at this time the blood would 
escape into the left auricle, as well as run through the proper channel, and 
be set in vibration by the impeding flaps at the mitral orifice. Here the 
bruit generated by this disturbance is borne with the reflux into the auricle, 
and thence to the back, and also by conduction through the apex to the 
front. Moreover, it is loudest in front and at the apex, because the heart 
is nearer the anterior than the posterior surface of the chest. Therefore, 
this murmur is most intense at the mitral area, systolic in rhythm, com- 
monly diffused to the left, and often audible near the inferior angle of the 
left scapula. 

In a similar manner during systole, the blood is being propelled by 
the right ventricle through the pulmonary aperture, and likewise the tri- 
cuspid valve is closed or very nearly so. Thus supposing that an obstruc- 
tion were to occur at the pulmonary orifice, there would be a systolic mur- 
mur, with point of maximum intensity in the pulmonary area and extension 
upward to the left, but not into the carotids. 

In the event of tricuspid insufficiency, part of the blood would flow 
back into the right auricle, and give rise to a systolic bruit, best heard in the 
tricuspid area, and spreading upward to the right. 

Anaemic Murmurs. — An anaemic murmur is always systolic in rhythm, 
loudest at the base of the heart, and often as audible in the aortic as the 
pulmonary area. With anaemia pure and simple there should be no cardiac 
hypertrophy. 

Diastolic Murmurs. — In diastole the aortic and pulmonary valves are 
closed, and the auriculo-ventricular valves open, while blood is flowing from 
the auricles to the ventricles. The vermicular contraction, styled cardiac 
systole, which was initiated in the veins and taken up by the auricles, has 
gone through the ventricles and reached the large arteries, wherein the recoil 
of the current finds a point of support at the closed semilunar cusps. 



332 DISEASES OF THE HEART. 

If the function of one or more of these cusps in the aortic valve be 
destroyed, each contraction of the artery will drive a portion of its contents 
back into the left ventricle; and the vibrations generated in this return 
stream against the disorganized valve will cause a bruit that is aortic in 
origin and diastolic in rhythm. 

Though this murmur of insufficiency is conveyed along the arteries a 
varying distance in the efflux, its main direction is backward with the reflux; 
not so much in the line of the ventricle as down the sternum, owing to the 
close proximity of this bone to the aortic valves, and its superiority over 
the heart as a conducting medium of sound. The point of maximum in- 
tensity of this bruit is more often at the lower end of the sternum than in 
the second intercostal space. Granting that the same thing could happen 
to the pulmonary valves, a diastolic murmur would be audible in the pul- 
monary area, but with an extension downward only. 

An aortic systolic murmur is loudest in the second right intercostal 
space close to the sternum, and a diastolic bruit is heard loudest at the lower 
extremity of this bone. In some instances these murmurs are heard only 
at mid-sternum, about on a level with the third costal cartilages. In others 
they are most intense in the second, and even the third intercostal space, 
close to the left edge of the sternum. Upon the exclusion of aneurism, a 
bruit within these precincts is presumably aortic and not pulmonary, espe- 
cially if the right ventricle is unenlarged. 

Pericardial Murmurs.— A pericardial is distinguished from a pleuritic 
friction mainly by the time and locality of its occurrence. Grating in the 
pericardium obviously is limited to the precordial region,, and is regulated 
by the action of the heart. That of the pleura* is most prone to take place 
in the infra-axillary regions, where pulmonary mobility is extensive. It is 
dependent upon the respiratory movements. 

Venous Murmurs. — In quality venous murmurs are blowing, cooing, 
and sometimes musical; and from the frequent resemblance of the noise 
to that of a humming-top, it. has been denominated venous hum. 

It is usually most distinct at the lower third of the external jugular 
veins, and more distinct in the right than in the left side. It is always con- 
tinuous in rhythm, but the intensity is often remittent because of the 
periodical acceleration of the stream by the action of the heart. The direc- 
tion is downward and inward along the subclavian and right innominate 
veins, so that it is now and then audible through the aortic area, and can be 
separated with a little care from the aortic sounds as well as from the 
respiratory murmur. When there is a question as to whether or not a given 
bruit is venous or arterial, pressure upon the vein above the stethoscope will 
stop the downward current and silence the venous hum. 



PULMONARY STENOSIS. 



333 



Cerebral Blowing'. — A blowing, systolic murmur, of variable intensity, 
is frequently heard over the anterior fontanel and sometimes over the 
carotids of children, between the ages of three months and six years. 1 

• Pulmonary Stenosis (Congenital Heart Lesion: Blue Baby). 

A. N. H., born May 7, 1904, was first seen by me when seven months old, in 
consultation with Dr. E. D. Lederman. 

Family History — It was the third child born with natural labor. The mother 
has had one still-birth and one miscarriage. Has one child 5 years old in good health 




•LOUD SYSTOLIC 
MURMUR, 



SYSTOLIC MURMUR. 

(very forcible thrill 
tiandmitted on palpation.) 



Dotted inner line denotes 
normal area of heart. Shaded 
line around heart — area of 
cardiac dullness on percussion. 



Fig. 108.— Case of Pulmonary Stenosis — Congenital — Blue Baby. (Original.) 

with no evidence of heart trouble. Both father and mother are in excellent health, 
and there is no evidence of heart or lung trouble, and no specific disease on either 
side. This child has been cyanotic. The toe nails and finger nails show typical 
clubbing and also blueness. On the slightest exertion the infant's skin assumes a 
very dark blue color. Dyspnoea is also present. The cutaneous circulation is very 
poof and the nurse informed me that for one-half hour after a tub bath there is an 
increased evidence of cyanosis. 

A loud blowing systolic murmur could be made out in the second intercostal 
space. There was also a weakness of the pulmonary second sound. The area of 
dullness was increased so that a right-sided hypertrophy undoubtedly existed. The 
murmur was not transmitted to the vessels of the neck. 

The infant was breast-fed by its mother for four and one-half months. There 
has been a tendency to constipation. The stool has been green and contained white 



1 1 am indebted to S. S. Burt & E. Le Fevre for some points in the above article. 



334 DISEASES OF THE HEART. 

curds at times. During the last few months the feeding consisted of equal parts of 
barley water and milk. When seen again the appetite was poor. The tongue 
slightly coated. The general condition one of restlessness by day and insomnia 
by night. The infant was very sensitive to cold and had a diffuse bronchitis 
associated with acute rhinitis. I ordered: — 

I£ Raw milk 12 ounces 

Rice water 24 ounces 

Granulated sugar 6 drachms 

Lime water 6 drachms 

Peptogenic milk powder 2 measures 

Divide in six bottles. Feed every 3% hours. 

As the food agreed very well, I ordered 1 ounce more of milk to the total 
quantity every second day until the infant received full milk undiluted. 
I ordered to relieve the dyspnoea and regulate the heart: — 

R- Sodium iodide 15 grains 

Sparteine sulphate 3 grains 

Elix. lactopeptin 2 ounces 

Half-teaspoonful three times a day. 

The progress of the case was excellent. When first seen by me there was no 
evidence of dentition. At the ninth month the child had two teeth and showed 
signs of general development. 

Prognosis. — As a rule the outcome of these cases is bad, although I 
have known a child with a pulmonary stenosis for the last twelve years. 
He is now 18 years old. These cases have a tendency to pulmonary disease, 
and are especially prone to develop tuberculosis. 

Treatment. — Peroxide of hydrogen or dioxygen in 5- to 10- drop doses 
in water, given several times a day, will liberate oxygen. Some cases will 
show a rapid improvement in the cyanosis during this treatment. 

Persistence of the Ductus Arteriosus Botalli. 

During the first four weeks after the birth of an infant, the ductus 
arteriosus is closed by an overgrowth of the cells in its inner wall. When 
abnormal conditions exist, such as septic infection of the new-born with 
thrombi, a breaking down of the cell growth takes place and results in the 
duct remaining patent. This may also result from defective respiration 
and an anomalous pulmonary circulation. 

The clinical symptoms of the patency of the ductus arteriosus are 
rapid hypertrophy and dilatation of the right ventricle, with co-existing 
dilatation of the pulmonary artery. There is also an increased area of 
cardiac dullness. Loud systolic murmurs are heard all over the chest, and 
a thrill of the anterior chest wall can be felt. Protrusion of the upper part 
of the sternum — dyspnoea rarely — cyanosis and a deathly pallor. 

Gerhardt states that dullness is found at the border of the second rib, 
in which region the systolic pulsation of the pulmonary artery can be felt. 



ENDOCARDITIS. 



335 



M. G., four months old. Was two weeks prematurely born. She was the 
second child. The first child died of diphtheria; it was also prematurely born, and 
died when its mother was four months pregnant with the present baby. The mother 
had a normal pregnancy, but was greatly troubled with headaches and dizziness, and 
suffered mentally over the loss of the first child. 

The Baby. — When the baby was six weeks old the mother first noticed that it 
breathed with difficulty. It had been vomiting continuously. Diarrhoea has existed 
for ten weeks. There is an occasional cough. Since two weeks the baby appears 
colicky and cries with apparent pain. 

Stat. Prws. — A pale, very anaemic looking child, with large fontanel, somewhat 
depressed, the size of a silver quarter. 

The Eyes. — There was a slight exophthalmus. The nose, somewhat depressed. 
Slight coryza. 

The Heart. — The area of dullness extends from the right side to the left border 
of the sternum, corresponding to the lower border of the third rib. The apex is 



FRONT. 



BACK. 




Fig. 109. — Child with Persistence of the Ductus Arteriosus Botalli. X 5 Loud 
murmur audible — blowing presystolic. (Original.) 

at the lower border of the fifth rib, immediately under the mamilla. The heart is 
somewhat enlarged toward the left side. 

Auscultation. — A loud presystolic murmur is heard over the whole area of the 
heart. There is marked abdominal respiration. The lungs are normal in percussion. 
Moist rales can be heard over both lungs. 

The Abdomen. — The abdomen is distended and is tympanitic on percussion. It 
feels doughy on palpation. There is no cyanosis of the fingers or toes. There is 
a mild dyspnoea. The adipose tissue is not very apparent. There is marked 
prominence of the subcutaneous veins of the scalp. 

The clinical history of the mother did not give any evidence of miscarriage, 
no syphilis, and no family tuberculosis. 



Endocarditis. 
This disease is of frequent occurrence during infancy and childhood. 
Congenital endocarditis has frequently been reported, so that it is assumed 
it must have existed during fcetal life. 



336 DISEASES OF THE HEART. 

Etiology. — Gerhardt and Bednar believe that the disease occurs quite 
frequently in young children, although the greatest frequency is noted 
between the sixth and the twelfth years. Acute rheumatism is very fre- 
quently followed by endocarditis. Chorea is also frequently accompanied 
by endocardial disease. Scarlet fever, measles, variola, varicella, diph- 
theria, typhoid, and tuberculosis, according to Beimer, are frequently fol- 
lowed by or associated with endocarditis. When endocarditis follows pneu- 
monia, pleurisy, or bronchitis, it is due to the invasion of pathogenic 
bacteria. These are the staphylococcus, according to Frankel and Sanger, 
and the pneumococcus, according to Netter and Weichselbaum. The germs 
enter the deeper portion of the pericardium through the epithelium, causing 
inflammatory conditions. It is quite likely that endocarditis is caused by 
such invasion in acute joint inflammations, in phlegmonous periostitis, 
lymphangitis, pericarditis, myocarditis, and puerperal infections. Bouchut 
has reported cases of endocarditis following erythema nodosum and hered- 
itary syphilis. Yon Dusch has reported endocarditis following extensive 
burns of the hand. 

Pathology. — The lesions occur most frequently on the valves of the 
heart. The valves on the left side of the heart are most frequently affected ; 
hence, the mitral is the seat of the lesions more often than the aortic valve. 
In studying a series of these cases given by Steffen, we find that about 4 
per cent, show lesions in the aortic valve. 

The pathological changes consist in hypersemia, swelling, and an 
infiltration of normal cells or new connective-tissue cells having a grayish- 
white color. There is a breaking down of the epithelium, besides which wart- 
like excrescences called vegetations are formed on the free border of the 
thickened valves (endocarditis verrucosa). The result caused by the last- 
named condition is that the vegetations prevent a proper closing of the valves, 
which latter results in insufficiency and stenosis. Fibrinous deposits are 
frequently, noted on the valves, and on being carried with the circulation 
may lodge in the cerebral arteries, causing either emboli or infarctions, 
according to Virchow. The last-named condition is exceptional in acute 
endocarditis. 

Symptoms. — Endocarditis, whether primary or secondary, begins with 
fever. Not infrequently the temperature rises to 102°, sometimes 103° 
F., and there is a corresponding increase in the pulse-rate. The pulse is 
rapid, irregular, and of low tension. Cyanosis is sometimes present, espe- 
cially so if myocarditis accompanies the attack. Sometimes a child will 
develop endocarditis without any special symptoms being present. Not 
until the heart is examined will the condition be diagnosed. Thus an 
important rule which has been previously mentioned is the necessity of 
always listening to the heart when a diagnosis is uncertain. Frequently 
a few days will pass without specific symptoms being recognized. A child 



ENDOCARDITIS. 337 

will show evidence of malaise and suddenly the characteristic blowing sys- 
tolic murmur will be heard at the apex. The murmur is usually trans- 
mitted to the left and can also be heard behind. It is frequently accom- 
panied by the thrill and by an accentuated pulmonic second sound. When 
dilatation results there will be a cardiac insufficiency. The murmur may 
gradually increase in intensity and in the same manner it may diminish 
until it is inaudible. When fever suddenly appears during the course of 
an attack of chorea, endocarditis should be suspected. In some cases 
dyspnoea may be present. 

The diagnosis is frequently obscure because a child will have no symp- 
toms of a definite nature. If, however, we are patient and carefully ex- 
amine the heart, we may be rewarded by making the diagnosis. It is im- 
portant to examine all the organs of the body before making a positive 
diagnosis, if obscure or no cardiac symptoms exist. 

A cardiac murmur heard during an acute attack of rheumatism, or 
during the course of an acute infectious disease, is usually indicative of 
endocarditis, especially if on pressure with the stethoscope the murmur 
remains permanently. Associated with the murmur there is usually a rise 
in temperature. 

Inspection will always show a rapid and diffuse apex-beat. 

Palpation will confirm this observation and may reveal a strong but 
irregular heart action. 

Percussion is usually negative. ■ 

Physical signs are due to (a) insufficiency, (b) roughening, (c) ste- 
nosis, depending on changes in the valves. The character of the murmur 
depends on the valve involved and the lesion of the valve. In mitral regur- 
gitation we have a systolic murmur with greatest intensity over the apex. 
It is usually transmitted to the side, and also heard behind the sternum. 

Differential Diagnosis. — In mitral stenosis we have a presystolic mur- 
mur with the greatest intensity over the mitral area. 

In aortic regurgitation we have a diastolic murmur with the greatest 
intensity over the aortic valve, and transmitted down the sternum. 

In aortic roughening we have a systolic murmur with the greatest 
intensity over the aortic valve. Distinct murmurs can be heard at the 
valves of the right side. 

An embolism in some portion of the body is frequently the sign of a 
heart lesion. If the embolus reaches the brain, hsemiplegia is the usual 
result. If it reaches the lungs severe dyspnoea may result. An embolus 
in the mesentery may result in diarrhoea. If in the kidneys, hematuria may 
result. When it reaches the limbs it means an obstructed circulation. 

Prognosis and Course. — Endocarditis if carefully managed with rest 
and strengthening diet will improve. I have seen children with endocardial 
murmurs improve after a few weeks, when put to bed amid quiet surround- 



338 DISEASES OF THE HEART. 

ings. As a rule the prognosis is bad and the course of the disease tends 
to become chronic. In giving an opinion as to the outcome of a case of 
valvular lesion, we must remember that we are dealing with a damaged 
heart, and that months or years may pass before recovery can take place. 
A fatal outcome will be the result of carelessness or mismanagement. 

Treatment. — Nothing will do more good than absolute rest in bed. 
Small doses of codein or Dover's powder act very well. If endocarditis 
accompanies or follows rheumatism, then the salicylates should be given. 
An ice-bag over the heart is frequently useful. If the pulse is very rapid 
or the heart's action is feeble, then digitalis or strophanthus should be 
given. 

The tincture or an infusion of digitalis made from English leaves is 
the best. A point to remember is that digitalis has frequently an accu- 
mulative effect so that the pulse must be carefully guarded during its 
administration. When this is the case the administration of the tincture 
of strophanthus will be found very serviceable. In some children digitalis 
will be badly borne owing to its irritant action on the gastric mucous 
membrane. In such cases sparteine or strophanthus should be prescribed. 

Adrenalin chloride solution taken internally increases the blood pres- 
sure, stimulates the heart, and retards the pulse-rate. It is better than 
digitalis, as it does not irritate the gastric mucous membrane, and it is 
non-cumulative. 

B Sol. adrenalin chloride 1-1000 

Infants of 1 year, 1-5000, made with normal saline solution. 
Dose: Five to 10 drops, three times a day, gradually increased until effect 
on pulse is manifested. 

In some cases marked benefit will follow the use of iodide of sodium 
in doses of 1 to 5 grains, according to age. The iodides seem to steady the 
heart's action. I have found excellent results following their use. 

Malignant Endocarditis. 

This is commonly called ulcerative endocarditis. It is a rare condition 
in childhood. Harris reports a case in a child 4 years old. The type of 
the disease is similar to that noted in adults. This condition is rarely 
primary. It occurs with scarlet fever, erysipelas, pneumonia, rheumatism, 
and septicaemia, in which bacterial invasions of streptococci or pneumococci 
occur. These germs are found in the endocardium. 

Pathology. — Vegetations usually occur with ulcerations in the cavities 
and on the valves. Suppuration of the deeper tissues with abscess forma- 
tion is frequently noted. Osier states that the different parts of the heart 
are affected in the following manner : mitral valve, aortic, mitral and aortic 
combined, tricuspid and pulmonic valves, and the cardiac wall. The sec- 



PERICARDITIS. 339 

ondary lesions of malignant endocarditis are due to emboli. These are 
most frequent in the spleen and kidney, next in the brain, intestines, and 
skin, and, if. the right side of the heart is diseased, in the lungs. These 
emboli lead to the formation of red or white infarctions, to haemorrhages, 
or to multiple abscesses in the various organs and tissues in which they 
lodge. 

Symptoms. — It is extremely difficult to diagnose malignant endocar- 
ditis. The presence of symptoms of pyaemia or septicaemia, associated with 
a heart murmur, usually renders the diagnosis positive. There is a remit- 
tent type of fever, occasionally delirium and extreme prostration. The 
cerebral symptoms frequently suggest meningitis. There is sometimes a 
faint mitral regurgitant murmur. Not infrequently it is entirely absent. 
The spleen is usually enlarged. Hemiplegia as well as haematuria and 
rapid swelling of the spleen, or possibly symptoms of pneumonia, are fre- 
quently the result of emboli. 

Diagnosis. — This is at times extremely difficult. An examination of 
the blood for plasmodia will usually be the means of excluding malaria if 
the same is suspected. 

Prognosis and Course. — The rapidity of the onset and the malignancy 
of the disease go hand in hand. The outcome is usually fatal. 

•Treatment. — In addition to rest and a supporting, stimulating diet, 
nothing but relief of individual symptoms by routine treatment can be 
given. 

PEEI CARDITIS. 1 

This disease may exist with or without myocarditis or endocardial in- 
volvement. Large effusions occur more readily in children than in adults. 

Etiology and Causes. — Eheumatism is the most frequent cause of peri- 
carditis. Apparent mild forms of rheumatism, such as are frequently 
called "growing pains" by the laity, are quite often complicated by peri- 
carditis. In this manner the existence of the rheumatism preceding the 
pericarditis is strikingly brought out. 

Pericarditis is rarely a primary condition. Septic infection of the 
umbilicus occasionally causes this condition. 

Tuberculosis, scarlet fever, diphtheria, measles, typhoid, and influ- 
enza frequently precede a pericarditis. 

Baginsky found purulent pericarditis associated with phlegmonous 
erysipelas, grave forms of angina, caries of the ribs, fibrinous pneumonia, 
bronchopneumonia, gastroenteritis, furunculosis, phlegmon of the throat, 
and empyema. It not infrequently follows kidney disease and scurvy. 

Pericarditis is met with at any age. It has been met with in the foetus, 
according to Billard, Bednar, Hiiter, and Steffen. 



1 The anatomical outlines are illustrated and described in the article on "The 
Heart and Circulation." See "Introductory," Part V. 



340 DISEASES OF THE HEART. 

Bacteriology .— We most frequently meet with a staphylococcus aureus 
or streptococci, bacterium coli, and the diplococcus pneumoniae. 
Pathology. — Pericarditis may be divided into : — 

(a) Plastic pericarditis. 

(b) Pericarditis with serous or purulent effusion. 

(c) Adherent pericarditis. 

Any of the above-mentioned varieties consists of an inflammatory 
affection involving the serous covering of the heart and its reflection on 
the inner surface of the pericardial sac. 

Symptoms and Diagnosis. — The acute condition begins with fever 
reaching as high as 104° F. in some instances. Associated with this there 
is pain in the praacordial region. Dyspnoea is present. There may be left 
pleurothotonos (a bending of the body to one side). The pulse is usually 
rapid. When there is effusion the child will complain of either very sharp 
pains or merely a sense of heaviness and discomfort. Syncope, singultus, 
and severe manifestations are present in the severer types of the disease. 
Not infrequently there may be delirium, twitching, and cerebral symptoms 
simulating meningitis. When effusions are abundant, cyanosis may occur. 

The physical signs resemble those of adults. In dry pericarditis a 
double friction sound is heard over the prsecordial space. The friction 
sounds may vary in intensity. It may be a grating sound or it may. be a 
weaker rubbing sound. The friction sound or murmur is usually loudest 
at the base of the heart. Its intensity depends on the change of position 
so that it is louder when the child sits up or when it exerts itself as in 
walking or bending. When the child is quiet or lies on its back the friction 
sound is weaker. 

When a large area of the heart is involved, the friction murmur will 
also be heard with great intensity at the apex. When a child is placed in 
the knee-elbow position, the apex beat which could not be palpated may 
reappear. This is an important symptom of exudative pericarditis. 

The pericardial friction sound may be purely systolic at the beginning 
of the disease; thus we must differentiate it from an endocardial murmur. 
Its maximum intensity is at the base and it is not transmitted beyond the 
praecordial region, whereas in acute mitral endocarditis we have the maxi- 
mum intensity of the systolic murmur at the apex. It is transmitted to the 
side, and heard also posteriorly at the angle of the scapula. Friction sounds 
disappear as serum is poured out and reappear as it is absorbed. The sound 
is not transmitted and is independent of the respiratory movement. If 
effusion takes place the apex-beat will be found displaced, sometimes up- 
ward and outward or indistinct; in some instances it cannot be found at all. 
There may be bulging of the chest wall. The intercostal spaces become 
very prominent. On palpation there is an absence of vocal fremitus over an 
area usually occupied by the lung. 



PERICARDITIS. 341 

Percussion gives an area of marked dullness or flatness of triangular 
shape, the base being below and the apex above. The normal area of car- 
diac dullness is increased in all directions, and this dullness extends beyond 
the limits of the heart. On auscultation the heart sounds are feeble and 
distant. Endocardial murmurs may also be present. In infants physical 
signs are often entirely wanting, or the normal sounds may be feeble, dis- 
tant, or absent. 

The usual duration of acute pericarditis is from one to three weeks. 
The ordinary dry form, with the resulting adhesions, may be followed by 
a subacute or chronic form of the disease. In the serofibrinous form the 
serum is usually absorbed quite promptly, and only adhesions are left or 
a chronic inflammation follows, with exacerbations in each recurrence of 
rheumatism. In the purulent form of the disease in young children, death 
is the most frequent termination. If the pus is evacuated or spontaneous 
opening takes place, there may be recovery, but always with more or less 
extensive adhesions remaining. 

Prognosis. — The prognosis should always be looked upon as very grave. 
StefTen states that out of 35 cases only 6 recovered. When this disease 
follows pyaemia, or when it is a sequela to the acute infectious diseases, the 
prognosis is very bad. When it is associated with rheumatism the ultimate 
results, by reason of adhesions and dilatation, are usually very serious. 

Treatment. — Children affected with acute pericarditis should be put 
to bed and kept quiet. An ice-bag placed over the heart and small doses 
of opium or Dover's powder seem to steady the heart's action. The value 
of aconite in this disease must not be forgotten, especially when we have 
excessive heart's action. Very bad effects have been noted by me when 
either pilocarpine or jaborandi was given. The specific effect of salicylate 
of soda, salol, or salophen must be remembered if due to rheumatism. If the 
salicylates irritate the gastric mucosa, then inunctions with salicylic prepa- 
rations such as mesotan or rheumasan may be given three times a day. 
Phenacetin in 2- to 3-. grain doses may be given every three hours if the 
child complains of pain and if fever is present. Good results may frequently 
be had from salophen in 2- to 3- grain doses. 

Aspiration of the Pericardium. — When symptoms of collapse, cyanosis, 
irregular pulse, and severe dyspnoea are present, then aspiration may do 
good. If, on aspiration, we find pus present, an incision should be made 
and drainage should be used as we would in a case of empyema. The proper 
place to puncture the pericardium is a point a little to the left of the 
border of the sternum in the fifth intercostal space, the needle being directed 
upward and outward. It must be remembered that by this means only 
can relief be expected. Keating states that "of 18 cases punctured only 4 
recovered." 



342 DISEASES OF THE HEART. 



Chronic Pericarditis with Adhesions. 

When children suffer with repeated attacks of rheumatism complicated 
by pericarditis, a chronic pericarditis frequently remains. Holt describes 
a case of a child sixteen months old in which the pericardial sac was com- 
pletely obliterated. Associated with this condition we frequently have 
chronic myocarditis, hypertrophy, dilatation, and valvular lesions, so that 
no portion of the heart muscle or its lining membrane is normal. 

Symptoms and Diagnosis. — According to Broadbent, there is a con- 
traction seen behind in the infrascapular region, sometimes on the left, 
sometimes on the right, side in the region of the eleventh or twelfth rib. 
Anteriorly we have the characteristic sign. It is a systolic retraction 
of the chest at or near the apex of the heart, sometimes at the tip of the 
sternum. This is due to the external pericardial adhesions, and is often 
better made out by palpation than by inspection. After the systole there 
is a rapid rebound, known as the diastolic shock. A collapse of the cervical 
veins during the diastole. of the heart, known as Friedreich's sign, is also, 
seen. Sometimes we see an inspiratory swelling (Kussmaul). In addition, 
the pulsus paradoxus is significant of the presence of pericardial adhesions, 
or rather of the dilatation that succeeds the adhesions. The pulse is small 
and feeble during inspiration, assuming greater strength during the period 
of expiration. 

Percussion shows an increase in the cardiac dullness in all directions. 
The position of the apex and the percussion outline of the heart do not 
change with the posture of the patient, and the cardiac dullness is but 
little affected by full inspiration. A systolic murmur is often present. 
The diagnosis of adherent pericardium always presents difficulties, but it 
can be made with tolerable certainty in a considerable portion of the cases. 
On account of the enlargement of the heart and the frequency of murmurs, 
it is usually mistaken for valvular disease. The lesion is a permanent one 
and tends to increase. If a child suffers with valvulitis and the symptoms 
do not yield to digitalis, then adhesive pericarditis should be suspected. 

Treatment. — There is no known method of treatment which will mod- 
ify or improve this condition, excepting a supporting diet with absolute 
rest in bed and general restorative treatment. It is very important to 
watch the emunctories and stimulate them if their action is sluggish. 

Tuberculosis of the Pericardium. 

This condition is rarely met with as a primary process ; it is chiefly met 
with as a secondary process. It usually partakes of a general tuberculous 
process in which aU the organs of the body participate, among them the 
pericardium. 



MYOCARDITIS. 343 

Diagnosis. — The diagnosis of this condition depends on the symptoms 
which nsnally accompany pericarditis. The tubercular nature of the dis- 
ease must depend on the presence of tubercle bacilli in the exudation, 
although Unger denies the possibility of making such a diagnosis. Most 
probably a positive diagnosis will be made — as in many obscure lesions — 
post mortem. 

The treatment is the same as that previously described in the article 
on "Acute Pericarditis." 

Hydropericardium. 

Occasionally we meet with cases in which the symptoms of dyspnoea 
and cyanosis rapidly develop. Steffen maintains that such alarming symp- 
toms frequently occur within a few hours, and that the same will some- 
times disappear under appropriate treatment in a few days. 

Pathology. — A transudation of serous liquid in the pericardium with- 
out inflammatory process is usually a secondary condition in which drop- 
sical effusions appear. Usually hydremic conditions of the blood, such as 
the result of long-continued fevers in infectious diseases, tuberculosis among 
others, predispose to this condition. 

The prognosis depends upon the cause leading to this condition. 

The treatment is chiefly restorative, and will depend on maintaining 
the strength of the child by careful diet and hygiene. 

Myocarditis. 

An inflammatory condition involving the heart muscles; may be either 
acute or chronic. It occurs as (a) parenchymatous, (b) interstitial. 
Steffen has reported 33 cases. It is met with more often in boys than in 
girls. 

This affection is very frequently seen during the convalescence of diph- 
theria. It is also a frequent complication of scarlet fever. I have met this 
complication in the wards of the Willard Parker and Riverside Hospitals. 

Causes. — When it is primary it is due either to rheumatism, congenital 
syphilis, or tuberculosis. Secondary, it is due to endocarditis, pericarditis, 
toxins from infectious fevers, or phosphoric, arsenic, or lead poisoning. 
Traumatism has also caused myocarditis. 

Pathology. — The heart muscles appear pale, soft, and friable. The 
whole heart is not always affected; certain portions may show evidences of 
degeneration and fatty infiltration, while another portion may be normal. 
The myocardium is very susceptible to the toxins of infectious diseases. 
This is especially true when diphtheria and scarlet fever have existed prior 
to the heart lesions. 

Symptoms. — There are two positive signs of myocarditis, arrhythmia 
and bradycardia. The pulse is very feeble and slow, in some cases irregular. 



344 DISEASES OF THE HEART. 

Sometimes the pulse rate is increased. The extremities are usually cold. In 
some cases there is a slight rise of temperature, 100° to 101° F. Other cases 
show a subnormal rectal temperature of 96° to 98° F. It is very evident that 
the toxins of the infectious diseases inhibit the proper action of the thermic 
centers. I have seen distinct vasomotor disturbances, such as unilateral 
flushing, affecting one cheek or the lobe of one ear. The child shows a 
marked general depression. There is a general devitalization noticeable ; also 
marked apathy. The child appears listless and prefers to rest. 

The Heart. — There is an irregular, very rapid heart action. The 
heart sounds are very indistinct. When the above symptoms occur during 
the course of infectious diseases, myocarditis should be suspected. Some- 
times there is faintness, severe dyspnoea, and cyanosis. Not infrequently 
there is albumin in the urine. Dilatation and hypertrophy sometimes occur 
without showing distinct symptoms. The ratio of the pulse and respiration 
will be disarranged. 

Diagnosis. — In some cases this is very difficult to make. The presence 
of a slow pulse and muffled heart sounds during the beginning or during the 
convalescence of acute infectious diseases should always lead to the sus- 
picion of myocarditis. A slow pulse in itself should always be looked upon 
as ominous. 

Frequently a diagnosis of myocarditis is made at the autopsy when 
no positive symptoms of the condition were present during life. 

Prognosis. — The prognosis is certainly not good. Barely do we find 
cases of myocarditis recover. This is especially true when myocarditis com- 
plicates the acute infectious diseases and the child is in a devitalized 
condition. 

Treatment. — Excitement or exertion may cause sudden death. The 
child requires absolute rest. It should be put to bed in a recumbent posi- 
tion. High saline injections at a temperature of 115° to 120° F., using 
several quarts of salt water, can be tried two or three times a day. The 
diffusible effect of the hot saline, and consequently the tendency to eliminate 
toxins through the kidney, should serve as a valuable therapeutic adjunct. 
Life can certainly be prolonged by this measure; if it is cautiously done, 
so as not to exert the child's heart, the result will be apparent very soon. 

Another diffusible stimulant which has served me very well is the 
injection of hot water to which several grains of carbonate of ammonia 
have been added. In some cases of severe cardiac depression I have seen 
good results from the injection of: — ■ 

IJ Sp. ammon. aromatic y 2 drachm 

Hot water 1 quart 

Inject through a rectal tube into the colon, at a temperature of 110° to 115° F., 
once in six hours, alternating with the hot saline. 



MYOCARDITIS. 345 

In syphilis or tuberculous conditions the treatment should be specific. 
When evidences of heart-failure exist, strychnine, caffein, whisky, aromatic 
spirits of ammonia, and nitroglycerine may be used. Spartein in small 
doses (V10 grain every hour) may be given. The value of concentrated 
food is greater in this condition than in any other. 

Feeding". — No drug will give as much strength to the body as food. 
Food should be given very frequently in small quantities. A cup of con- 
centrated chicken broth or beef broth should be given, and two hours later 
the white of two or three raw eggs with sweetened coffee. Milk punch, 
cocoa, chocolate, or strained oatmeal gruel may be given. One of the above 
foods may be given every two hours. Several ounces may be given at each 
feeding. The outcome of the case depends upon strengthening the heart. 
My plan has been to give the strychnine in the food. Drugs have a more 
diffusible effect and seem to enter the circulation better when combined 
with hot food. If for any reason the stomach is sensitive and does not 
retain food, rectal feeding with peptonized milk may be necessary along 
with the hot salines previously mentioned. 



CHAPTER III. 

DISEASES OF THE LIVER. 

The Liver. 

The liver in nurslings is relatively larger than in adults. To examine 
the liver place the child on its back with the legs slightly flexed toward the 
abdomen. Have the child, if possible, breathe with regularity. 

Position of Liver. — Dullness can be made out from the fifth inter- 
costal space in the mammary line to about one inch below the border of 
the ribs. In the axillary line it reaches from the seventh intercostal, and 
posteriorly a dullness is made out at the ninth intercostal space. It extends 
downward and can best be made out by palpating. 

Birch-Hirschfeld found the average weight of the liver in the new- 
born infant about four and one-half ounces (127 grams). 

Steffen, who has devoted considerable attention to the liver, states that 
the left lobe is relatively larger in the child than in the adult. 

Bile. 

The quantity of bile in the gall-bladder is very small. It is of a golden- 
yellow color, and has a neutral reaction. Its specific gravity varies from 
1014 to 1053. According to Baginsky, the bile in nurslings contains or- 
ganic salts — cholesterin and lecithin — fat, and various acids in less pro- 
portion than in adults. Baginsky was able to demonstrate the presence 
of glycocholic acid. The presence of a much less quantity of bile-acids in 
the infant is a beneficial physiological condition. It is a well-known fact 
that these acids inhibit the digestive action of the pepsin and of the pan- 
creatic juice. Another point is that the absence of a bile-acid prevents the 
assimilation of large quantities of fat, as it is impossible to split up the 
fat into fatty acid and glycerine. Thus, fermentative processes are much 
more frequent in nurslings and appear with greater intensity than in the 
adult, because of the biliary acids. The amylacea and all substances con- 
taining flour are — owing to the above-described condition of the pancreatic 
juice and the bile — not fit substances to give the infant, especially during 
its first three months of life, although very small quantities can he digested, 
and after the fourth month are not only digested, but also absorbed. 

Baginsky and Sommerfeld found large quantities of mucin in the 
bile. 

Jaundice (Icterus). 1 

There are two forms of jaundice met with in children: first, hepato- 
genic; second, hematogenic. The most common form seen in children 



1 Icterus neonatorum is described in Part II, "Diseases of the New Born.' 
(346) 



ABSCESS OF THE LIVER. 347 

is a catarrhal jaundice. This is due to an extension of the catarrhal process 
from the stomach to the duodenum, causing catarrh of the bile ducts. (See 
article on "Gastroduodenitis.") In the hepatogenic form there is an ob- 
struction to the flow of bile into the bowel. It is also called obstructive 
jaundice. 

In the hematogenic form there is no obstruction to the flow of bile, 
but the jaundice is due to blood conditions. We find jaundice in sepsis, 
in malaria, and in typhoidal conditions. Mechanical obstructions, such as 
round worms entering the common duct, have been reported, but they are 
rarities. 

Acute Congestion of the Liver. 

In literature very little light is shed on this condition. Some authors 
state that malaria and other poisons, particularly phosphorus, may cause 
this condition. I believe that acute congestion of the liver is frequently 
associated with acute gastric catarrh. It is also, no doubt, one of the factors 
on which intestinal indigestion hinges. The symptoms are mainly those 
of enlargement which can be made out by palpation and functional de- 
rangement such as will be considered in the next article. 



Abscess of the Liver. 

While the condition is rare in children, Legrand found 102 cases 
reported : — 

Dysenteric abscesses 31 

Traumatic abscesses 19 

Appendicitis abscesses 15 

Typhoid abscesses 6 

Tuberculous abscesses 10 

Worms 13 

Pyemia . . .• 2 

Doubtful 6 

In the chapter on the intestinal tract I have referred to worms as a 
causative factor. Ascarides have been found in the bile duct and the 
hepatic duct associated with multiple abscesses. They • have also been found 
in the pancreatic duct. 

The symptoms of fever, pain, and swelling in the region of the liver 
are very marked. Aspiration will aid in making the diagnosis. 

The prognosis depends on the early recognition of the abscess and its 
immediate relief by free incision. 

Treatment. — An exploratory puncture should be made early in the dis- 
ease, and, as soon as pus is located, free incision should be made. 



348 DISEASES OF THE LIVER. 

GrALL-STONES (CHOLELITHIASIS). 

Authentic cases of gall-stones in childhood are rare. The symptoms of 
biliary colic with jaundice, pain, and fever are identical with the adult type 
of the disease. The diagnosis can be made by the aid of an x-ray examina- 
tion. No operation should be performed until a radiogram strengthens the 
diagnosis. 

Functional Disorders of the Liver. 

Functional Derangement. — This very common condition is character- 
ized by either a total absence or a diminution in the quantity of bile secreted. 
This functional disorder usually causes very dry, grayish or whitish, "clay- 
colored" stools; also flatulence. The urine is of a very dark reddish or 
brownish color. Frequently the skin and conjunctival mucous membrane 
are pigmented. The temperature may reach 101° F. ; rarely higher than 
103° F. If after rest, proper diet, and hepatic stimulation the fever per- 
sists, then the possibility of abscess in the gall-bladder should be 
remembered. 

Treatment. — Calomel, podophyllin, or elaterin in small doses. The 
salines and phosphate of soda in 5- or 10- grain doses can be given. Diluted 
hydrochloric acid or diluted nitromuriatic acid, in 1-drop doses, is a good 
bile stimulant. In some cases a gentle faradic current and massage may 
do good. A cold spray over the liver will also tone the same. Large quan- 
tities of liquids will sometimes aid in relieving functional disturbance of 
the liver. 

Displacement of the Liver. 

The liver may be displaced downward when the ribs are contracted in 
size. This condition is best noted in rickets. The liver may also be dis- 
placed by pleural effusions. It is found much lower in diseases wherein 
emaciation takes place, such as in marasmic or tubercular manifestations. 
In these latter conditions relaxation of the abdominal walls permits the 
liver to occupy a position much lower than normal. 

Displacement Due to Diseases of the Adjacent Organs. — The liver is 
sometimes displaced by tumors arising in the right pelvic region, chiefly 
from swelling associated with the right kidney. In a case of mine (see 
chapter on "Pyelitis") the kidney pushed the liver upward and to the left. 
The liver returned to its normal position after the diseased kidney was 
removed. 

Several years ago, at the Kaiser and Kaiserin Friedrich Children's Hospital of 
Berlin, I saw a case of a child having a supposed tumor involving the liver. While 
all believed that the swelling was associated with the liver, after the abdomen was 
opened it was found that the kidney was the seat of the trouble and that the liver 
was unaffected. 



AMYLOID DEGENERATION. 349 



Descended Liver. 

Eowland G. Freeman, in studying a series of 496 autopsies in children, 
states that he has met, not very rarely, with descended liver. These en- 
larged livers were found in children suffering with tuberculosis and lobar 
pneumonia. In his cases the liver had slipped down the right side of the 
abdomen. 

Amyloid Degeneration - (Waxy Liver). 

This is an extremely rare condition. Freeman mentions but two cases 
in his large post-mortem experience, one case associated with tuberculous 
disease of the vertebrae and psoas abscess, and the other case in a child 
suffering from progressive anaemia. The liver and kidney were waxy in 
both cases. 

Experimentally, amyloid degeneration has been produced by the action 
of the toxins of the staphylococcus pyogenes aureus. 

Symptoms. — Special symptoms which could be called those specifically 
due to this condition cannot be described. The symptoms of the disease 
associated with amyloid degeneration are present on palpation. The liver is 
enlarged, the surface very smooth and hard, without tenderness. The 
spleen is also enlarged. Dropsy is usually present. The latter symptom 
must not necessarily be due to the kidney, but may result from pressure 
of the swollen liver upon the vena cava. When this disease is associated 
with syphilis, then symptoms of the latter disease may also be found. 

The prognosis is usually bad. 

Treatment. — This depends on the symptoms, which require urgent 
management. Syphilis, when present, requires anti-syphilitic treatment. 
The outcome of the case depends on restorative treatment, including 
nutrition. 

Fatty Liver. 

Fatty degeneration of the liver is very frequently noted in children. 
Wollstein has found 201 cases of fatty liver in 345 consecutive autopsies. 
Freeman and Long studied a series of 296 autopsies at the Foundling Hos- 
pital, and found 202, or about 68 per cent,, fatty livers. This disease is 
not as frequently found associated with wasting diseases as is claimed. 

The following classification of causes or conditions with which fatty 
liver is associated is given by C. Oddo, in Grancher's Maladie de VEnfance: — 

1. Intoxications : Phosphorus, alcohol. 

2. (a) Infections, acute: typhoid fever, measles, scarlet fever, small- 
pox and diphtheria, bronchopneumonia, acute general tuberculosis, and 
diarrhoea. (b) Infections, chronic: chronic tuberculosis, hereditary 
syphilis. 



350 , DISEASES OF THE LIVER. 

3. Maladies of nutrition : chronic gastroenteritis, rachitis. 

4. Fatty liver associated with the hepatic lesions. 

Cirrhosis op the Liver (Interstitial Hepatitis). 

Two varieties of cirrhotic liver are seen in children; they are: (a) 
atrophic, (b) hypertrophic. This condition is caused by the same factors 
that produce cirrhosis in the adult. The two most important factors that 
produce this condition are syphilis and the excessive use of alcohol. Freeman 
reports two cases in neither of which alcohol was the cause ' of the con- 
dition, nor was any acute disease reported prior to the cirrhosis. 

Symptoms. — Digestive disturbances, such as fullness in the abdomen, 
constipation, or diarrhoea, exist. The temperature is irregular. As a rule, 
the liver is not enlarged. 

Diagnosis. — This is sometimes extremely difficult and can only be 
determined positively by a post-mortem. 

Prognosis. — The prognosis depends on the cause. If due to syphilis, 
the prognosis is fair ; if due to alcohol, then it is grave. 

Treatment. — The treatment of the case depends on the symptoms 
presented. 

Focal Necrosis. 

This is usually found associated with infectious diseases. It has been 
observed resulting from the toxin of diphtheria and measles. Freeman 
found focal necrosis in 4 cases out of 14 consecutive autopsies on measles 
cases. 

Summary. — "1. Descent of the liver down the right side of the abdo- 
men, so that the right lobe reaches below the crest of the ilium, occurs oc- 
casionally in infants, and particularly in those in whom the liver is 
enlarged. 

"2. Fatty livers occur very frequently in the infants and children 
who die at the New York Foundling Hospital, or in about 41 per cent, 
of all cases. 

"3. The condition of nutrition of the child, as expressed by the absence 
of fat in general and wasting of tissue, apparently has no connection with 
the fatty condition of the liver, the condition of nutrition in the cases 
having fatty livers averaging about the same as in the whole number of 
cases. 

"4. Fatty livers occur rarely in the following chronic wasting diseases : 
marasmus, malnutrition, rachitis, and syphilis, unless such condition be 
complicated by an acute disease. 

"5. With tuberculosis fatty livers occur not more often than with other 
conditions. 



SUBPHRENIC ABSCESS. 351 

"6. Fatty livers occur most often with the acute infectious diseases and 
gastro-intestinal disorders. 

"7. The two cases of cirrhosis of the liver examined by the writer ran 
a comparatively acute course. The livers on section showed a marked 
hyperplasia of the so-called new-formed bile ducts. 

"8. Focal necrosis of the liver may be a lesion of measles." 

Bead article on "Congenital Obliteration of the Bile Ducts" in the sec- 
tion on "The New-born Baby." 

Subphrenic Abscess. 

This condition is very rare in children. It consists of an accumulation 
of pus above the liver, but beneath the diaphragm. Carl Beck has described 
this condition in extenso in a paper read before the New York Academy of 
Medicine several years ago. 

Meltzer 1 reports a case occurring in a child 2 years old. 

Jopson 2 has recently reported a case from the Children's Hospital, 
in Philadelphia. 

Maydl 3 has studied a series of 179 cases. Of these cases, which were 
found in all ages, 10, or 5.9 per cent., were under 15 years of age. The 
causes in Maydl's cases were attributed to the stomach and duodenum, 
intestinal, pericecal (including appendicitis), echinococcus, subcutaneous 
traumatism, cholangitis, perinephritis, metastatic wounds and gunshot in- 
juries, and caries of the ribs. 

Jopson, in reporting the Causes of 12 of his cases, includes appendi- 
citis, perforated gastric or duodenal ulcer, caries of the dorsal vertebrae, 
traumatism, and calculous cholecystitis. 

In a case reported by A. Frederici 4 a girl, 8 years old, had an abscess 
which ruptured into the lung. The diagnosis of subphrenic abscess, second- 
ary to liver abscess, was founded on tenderness over the liver region before 
the abscess ruptured, and on the absence of air in the abscess cavity. 

B'aginsky reported a case in a child, 2% years old, secondary to 
appendicitis. 



1 New York Medical Journal, June 24, 1893. 

2 Archives of Pediatrics, February, 1904. 

3 "Subphrenic Abscess," Wien, 1894. 

4 In Monatschr. f. Kinderheilk., July, 1903. 



CHAPTEE IV. 

DISEASES OF THE SPLEEN AND PANCREAS. 

The Spleen. 

One of the most difficult organs of a child to examine is the spleen. 
It can be palpated between the ninth and eleventh ribs. It is impossible 
to positively outline the spleen by percussion. For the purpose of examina- 
tion the child should be placed flat on its back with the thighs flexed. By 
gentle manipulation with the tips of the fingers, we can frequently in a 
quiet child press under the free border of the ribs and feel the smooth border 
of the spleen. Some authors maintain that when the spleen is palpable 
it is enlarged. I have frequently been able to palpate the spleen in per- 
fectly normal infants. 

There are no primary diseases of the spleen, although it is frequently 
the seat of tubercular disease. 

Enlargement of the Spleen (Splenitis). 

An enlarged spleen is frequently seen in various systemic conditions. 
It is one of the characteristic symptoms of many of the -acute infectious 
diseases. It is a prominent symptom of malarial infection and typhoid 
fever, and next to the condition of the blood itself is a very valuable aid 
in the diagnosis. In cachectic conditions and in such constitutional dis- 
orders affecting the blood, as, for example, in rickets, a very large spleen 
can frequently be palpated. An enlargement of the spleen reaching into 
the groin was seen by me in a case of rickets. The spleen, therefore, is a 
very valuable aid to diagnosis in many conditions. For a description of 
the method of examination see article on the "Spleen in the New-born 
Baby." 

Wanderjng Spleen (Movable Spleen, Lien Mobilis). 

When there is an elongation of the gastro-lienal ligament, the spleen 
can be readily moved. 

Causes. — Severe paroxysms of coughing, such as whooping-cough or 
traumatism, can cause this condition. 

Symptoms. — In young children there are no special guides. Older 
children complain of pain on the left side and vague abdominal pains. 
(352) 



THE PANCREAS. 353 

Diagnosis. — The diagnosis is made by palpating the wandering spleen. 

Treatment. — An abdominal bandage to support the abdomen will fre- 
quently aid in replacing the spleen. Barely will surgical treatment be 
demanded. 

The Pancreas. 

The pancreas is situated behind the stomach. It is about the height 
of the first lumbar vertebra. The function of the pancreas is known as 
the amylolytic function, namely, starch digestion, in reality the conversion 
of starch into sugar. 

Diseases of the Pancreas. 

Syphilitic tissue changes are frequently seen in the pancreas. Malig- 
nant tumors are occasionally reported in the literature. "When such lesions 
exist they tax the diagnostic skill of the specialist. The diagnosis is rarely 
made intra vitam. 



23 



CHAPTER V. 
DISEASES OF THE PERITONEUM. 

Acute Peritonitis. 

This is a very rare condition in childhood. It is most frequently 
seen in practice in the new-born, where the inflammation is the result of 
a pyogenic infection through the umbilical vessels. This has been de- 
scribed in the section on the "New-born Baby." 

Etiology .—This inflammation is frequently the result of traumatism. 
It may follow the operation for appendicitis or other operation on the 
abdomen. Cases have been reported where an infection such as gonor- 
rhoea or vulvovaginitis has extended into the uterus or into the perito- 
neum. This condition may frequently accompany Pott's disease or peri- 
nephritis, and may also follow deep-seated burns in which cellulitis or 
erysipelatous inflammation exists. 

I have seen peritonitis as a complication of scarlet fever in hospital 
and private practice. 

Bacteriology. — The streptococcus is most frequently found to be the 
cause of peritonitis in the new-born. Sometimes the pneumococcus and 
the bacterium coli commune are found. 

Pathology. — Serous Form: There is a large outpouring of serum 
which is clear, and there is a small amount of lymph associated with it. 
When recovery takes place the serum is absorbed. Adhesions usually 
follow. 

Fibrinous Form. — The peritoneum is intensely congested, the blood- 
vessels injected, and a large amount of lymph is thrown out with very little 
serum. The pathological process corresponds to that condition seen in 
fibrinous pleurisy. Firm adhesions resulting in the formation of connect- 
ive-tissue bands usually remain. 

Purulent Form. — A large amount of lymph and pus are present with 
the usual evidences of inflammation. The abscess is rarely localized or 
isolated from the rest of the peritoneum by a thick wall of fibrin. Spon- 
taneous evacuation of pus through the vagina, rectum, bladder, or um- 
bilicus has been reported. Such cases may recover. As a rule, purulent 
peritonitis is fatal. 

Symptoms. — The symptoms of fever, vomiting with pain, and uniform 

distention of the abdomen are usually present. There is also tympanites, 

and when liquid is present fluctuation can be felt. The child is usually 

found flat on its back with the legs flexed. Diarrhoea exists in some cases, 

(354) 



CHRONIC PERITONITIS. 355 

constipation in others. The child appears very sick and suffers continuous 
pain. The following case occurred in my practice : — 

Jessie M., 2 years old, had typical symptoms of influenza. There were coryza, 
sneezing, and a temperature of 104° F. At this time there had been a house 
epidemic, and all members of the family were suffering with influenza. The child 
had anorexia and vomiting, and cried continuously as if in pain. The abdomen was 
distended, and constipation reported. A soap-water enema was ordered, and, 
although a good result followed, the crying continued. The abdomen was tympanitic 
on percussion and the uniform distention continued. An ice-bag was ordered, but 
gave no relief. Local applications of warm antiphlogistine poultices seemed to afford 
relief. Chamomile injections at a temperature of 115° F. were ordered given into the 
colon. When the same passed off another injection of 8 ounces of warm olive-oil 
not only relieved the child, but produced sleep. These injections were repeated three 
times a day. Codeine with calcined magnesia was ordered to relieve pain and for 
the antifermentative effect. 

Feeding. — Whey was given every four hours and several teaspoonfuls of 
Mulford's predigested beef with whisky every two hours. The disease lasted about 
two weeks. The child recovered. 

Prognosis. — This disease is frequently fatal, especially the purulent 
variety. The most favorable cases are those in which there is a sero- 
fibrinous exudation. The outcome depends on the vitality at the time of 
illness. 

Treatment. — Warm applications have served me best, although some 
authors, especially the Germans, prefer ice. Hot, moist flannels to which 
15 to 30 drops of turpentine have been added will usually relieve tym- 
panites. Codeine should be given until the child is comfortable, 1 / 10 
to V 5 grain, every two hours or oftener. My results have been best when 
milk was omitted. Soup or broth may be given. Whey is valuable in this 
condition; also white of raw egg well beaten with sweetened water. The 
treatment described in the clinical case above cited is my usual method 
adopted. The high colon flushings are cleansing and soothing. When 
great prostration exists, instead of using chamomile tea and warm olive-oil, 
normal saline solution has a more toning effect. Special symptoms, such 
as collapse, require strychnine, nitro-glycerine, or caffeine sodium benzoate. 
Also liberal stimulation with champagne or whisky. Oxygen if cyanosis 
exists. 

Operative Treatment. — If symptoms of appendicitis exist, then an 
operation may do good. If a sudden collapse is noted perforation should 
be suspected and the surgeon consulted at once. 

Chronic Peritonitis (Xon-Tuberculous). 

Many authors doubt the existence of a non-tuberculous peritonitis. 
Henoch believes that we have a distinct variety of chronic peritonitis which 
bears no relation to tuberculosis. 



356 DISEASES OF THE PERITONEUM. 

Symptoms. — -In a distended abdomen associated with ascites the liquid 
can be made out by palpation. There may be diarrhoea or there may be 
constipation. Dyspeptic symptoms are always present, and there is a 
slight rise of temperature. There are no other symptoms of tuberculosis, 
and as a rule no other complications present. Anaemia is usually very 
marked. 

A child 8 years old was seen by me during my service in the German Poliklinik. 
He was a bottle-fed and rachitic boy. He had suffered with a very severe acute milk 
infection, resulting in cholera infantum and peritonitis. The child developed 
symptoms of athrepsia infantum. Several years later the child had a swollen, tym- 
panitic abdomen and a waA r e of fluid could be made out by careful palpation. I aspi- 
rated about 1 pint of a yellow serous fluid. The same was examined and no tubercle 
bacilli or other bacteria were found. The condition improved. The case was seen 
by me twice a month, and it was necessary to tap the abdomen each time to relieve 
distention. The child was under observation about six years. During this time 
large doses of iodide of sodium, codliver-oil, and iron were ordered. A change to 
the country seemed to do the most good. The child is well to-day. 

Tuberculous Peritonitis. 

The peritoneum frequently participates in a general tuberculous con- 
dition. It may, however, be an entirely independent disease; that is, it 
may occur as the primary lesion of tuberculosis. Biedert 1 collected a series 
of 883 autopsies on tuberculous children of various ages. He found the 
peritoneum affected in 18 per cent. The disease may be either acute or 
chronic. 

Pathology. — In tubercular peritonitis the lesions are those of a general 
miliary tuberculosis. There are usually not very many tubercles scattered 
through the peritoneum. When the ascites is present then the tubercles 
are far more abundant. The omentum and mesentery participate in the 
tuberculous process. The liquid present may be brownish-colored serum 
containing blood ; it may be serous or yellowish and contain pus. 

The fibrous form usually shows adhesions between the loops of intes- 
tine or between the intestine and the abdominal wall. In the ulcerative 
form there is usually a fibrinous exudation. This form usually follows the 
miliary or fibrous variety. 

Symptoms. — Well-marked evidences of peritonitis can usually be made 
out when ascites and tympanites are present. When fever is associated 
with it in addition to evidence of cough or other physical signs in the lungs, 
then the diagnosis is not doubtful. Sometimes the tubercular or non- 
tubercular forms of chronic peritonitis will render the diagnosis very diffi- 
cult. 

Differential Points. — Cirrhosis of the liver may cause an ascites. It 
is rare in very young children. If the history of syphilis is given the 



1 Jahrbuch fiir Kinderheilkunde, xxi, p. 178. 



TUBERCULOUS PERITONITIS. 



357 



same ma}' be suspected. In some cases a diagnosis can only be made when 
an exploratory puncture is made and the fluid examined. Even then the 
diagnosis may be difficult. The only method then left is to make a micro- 
scopical examination of the fibrous nodules or rarely by inoculation experi- 




Fig. HO.— Case of Tubercular Peritonitis Complicated by Tubercular 
Empyema. Enlarged Spleen. Rachitic Bottle-fed Infant. (Original.) 



ments. The following cases represent tubercular peritonitis as occurring in 
my private practice : — 

M. B., female, 2 years old, was brought to me with a history of cough, dis- 
tended abdomen, and severe constipation alternating with diarrhoea. The appetite 
was poor, and the child had lost considerable in weight and has not been well since 
an attack of measles which occurred about one year ago. Evidences of tuberculosis 
were made out. The stool contained mucus. Tubercle bacilli were frequently found 
in the mucous discharges. A cavity could be made out at the left apex. The child 
suffered with recurring pleurisy. The chest contained a large quantity of liquid 



358 DISEASES OF THE PERITONEUM. 

effusion for over four months. Nine ounces of a thin, greenish fluid was aspirated 
from the left side of the thorax. Examination showed tubercle bacilli and also 
streptococci. The abdomen was enormously distended, and a wave or distinct thrill 
of liquid could be felt by transmitted palpation. Extreme dyspnoea was caused by 
the pressure of this liquid on the diaphragm. By aspiration I removed 1000 cubic 
centimeters of a yellowish serous liquid from the abdominal cavity. Temporary relief 
was afforded, although the abdomen refilled very rapidly. It was necessary to tap 
the same once every six weeks. The child finally died of exhaustion. (See Fig. 110.) 
A second case occurred in a little girl, Katie B., about 9 years old, who was 
under the treatment of Dr. John H. Wurthman. The same symptoms as I have 
described in the previous case were found, general tuberculosis with especial pul- 
monary manifestations and symptoms of peritonitis. In this case I aspirated over 
three pints of liquid from the abdominal cavity.. The child gradually sank and died 
several months later. 

Prognosis. — When ascites is present the prognosis is not good, espe- 
cially if operative measures are undertaken. As a rule cases end fatally. 

Treatment. — For a number of years laparotomy was advised as the 
best method of treating tubercular peritonitis. Many successful cases were 
reported. It was believed that after the abdomen was. opened, drained, and 
sunlight admitted this latter agent aided the healing process. In recent 
years many pediatricians hold the opposite view. 

Light Treatment. — Not very long ago I saw a case of tubercular peri- 
tonitis (non-operative) which was progressing very nicely. It was under 
the treatment of direct sun rays, besides receiving an electric light bath for 
ten minutes each day. The influence of light has in recent years demon- 
strated its value, especially in tubercular manifestations. 

A very interesting monograph on this subject has been published by 
Aldibert, of Paris, 1892. Baginsky extols the value of operative procedures 
in tubercular peritonitis. The reader is referred to modern works on sur- 
gery for exhaustive data on this subject. 

The general treatment consists in restoratives, building up the body 
by nutrition, and by tonics when possible. 

Serum Treatment. — The use of streptolytic serum in doses of 10 to 30 
cubic centimeters is well worth trying. Antistreptococcic serum (10 to 
50 cubic centimeters) can be injected in daily doses of 10 cubic centi- 
meters, or the dose may be given every two or three days. 



Ascites. 

This is an accumulation of clear serum in the peritoneal cavity. When 
it is very severe there is, in addition to the uniform distention of the 
abdomen, a superficial enlargement of the veins. This is especially noted 
around the veins of the umbilicus. 



ASCITES DUE TO PERITONITIS. 359 

Causes. — Pressure upon the vena cava, or chronic heart or lung 
trouble, such as pleurisy, may give rise to ascites. In extreme leukaemia, 
anaemia, or kidney disease ascites may be present. 

Diagnosis. — The fluid can best be made out by tapping the abdomen 
and noting the transmission of the wave. On tapping the abdomen with 
one hand and pressing the other firmly against the opposite side, a wave of 
fluctuation can be made out. 

The symptoms, prognosis, and treatment will be considered in the 
article on "Ascites Due to Peritonitis." 

Ascites Due to Peritonitis. 

In the majority of cases ascites is caused by tubercular peritonitis. 
This condition resembles in its clinical and pathological aspects subacute 
or chronic pleurisy with effusion, or subacute pericarditis. 

Etiology. — Xo definite cause and no specific agent has yet been deter- 
mined. Most of the cases are associated with or follow rheumatism, mea- 
sles, or exposure to cold, and in rare instances injury to the affected parts. 
It is also seen associated with diseases of the kidney, liver, and intestines. 

Pathology. — The pathological lesions are very few. The effusion is 
usually of a greenish color. In addition to the serum there is fibrin, and 
in some instances adhesions. In some cases all the serous membranes of 
the body seem to participate and show evidences of inflammatory condition. 

Symptoms. — The early symptoms of ascites consist of general malaise. 
A child will have a poor appetite, complain of headache, and sometimes 
constipation. In other cases diarrhoea may exist. Pain is not present as 
a rule. The abdominal distention comes on gradually and progresses. The 
distention is usually the first symptom noted by the mother. The fluid 
can best be made out by tapping the abdomen as described in the foregoing 
article on "Ascites." Fever is usually absent, although there may be an 
evening temperature of 101° F. 

Prognosis. — The prognosis is fair, as a rule. I have seen many cases 
of ascites recover, leaving no trace of the former trouble behind. A cautious 
prognosis is advised if a tuberculous process is suspected. 

Treatment. — General Treatment: Such children must be put to bed. 
The diet should consist of concentrated liquid food. Xo solid meats should 
be permitted. Milk, if not well borne, should be peptonized or fermented. 
Buttermilk may be recommended. Fresh air and sponge bathing should be 
remembered as important hygienic factors. 

The body should be well protected to avoid chilling the surface. 

Treatment of the Effusion. — Small doses of calomel or podophyllin 
may be give** until liquid stools are produced. Diuretics such as cream of 
tartar, lemonade, or diuretin, in 5-grain doses, will stimulate the action of 
the kidneys and thus lessen indirectly the serous effusion in the abdomen. 



360 DISEASES OF THE PERITONEUM. 

Iodide of sodium in 3- to 10- grain doses should be given three times a 
day to promote absorption. It may be combined with iron in the follow- 
ing manner : — 

IJ Ferri et kali tartaric 1 drachm 

Sodium iodide : 1 drachm 

Elix. of lactopeptin, q. s. ad 2 ounces 

Sig. : One teaspoonful three times a day. 

Tapping the Abdomen. — Aspirating the liquid by means of a trocar 
and cannula is a valuable means of emptying the liquid. It is especially 
indicated if symptoms of dyspnoea due to pressure on the diaphragm are 
noted. 

If relapse occurs and the liquid continues to accumulate after several 
aspirations, then surgical treatment will be necessary. The occasional good 
results seen in tubercular peritonitis after a laparotomy should be remem- 
bered. 



CHAPTEE VI. 

DISEASES OF THE GENITAL ORGANS. 

Hernia. 1 

Herxia is occasionally seen in the new-born baby. It is overlooked 
in a good many cases until the size of the tumor indicates that something 
is abnormal, as there are no special symptoms (see article on "Hygiene of 
the Infant'' in the "New-born Infant 7 '). 

"In congenital hernia proper, anatomical conditions favorable to vis- 
ceral escape always tend to permanent spontaneous cure in infancy and 
early childhood. At birth the spermatic vessels are deeply covered by a 
thick layer of adipose tissue. The dartos and cremaster are then highly 
developed, giving the scrotum dimensions quite out of proportion in size 
to what they are in adult life. Serous cysts of the tunica spermatica and 
of the tunica vaginalis being very common, this condition also with the 
scrotum fullness may simulate hernia so closely that it is only by a most 
painstaking examination we are enabled to exclude them. On the other 
hand, a small fringe of omentum may come down with the cord and be 
completely overlooked." 

Thomas H. Manley, in his monograph on "Hernia and its Treatment," 
says : "The prevalent custom of applying a band or binder around the 
abdomen should be condemned. It conserves no useful purpose; the only 
excuse for it at all is that it retains the envelopes of the funis in position. 
If this firm, inelastic compression does not in many cases directly cause 
hernia in those predisposed to it, I am confident it often very seriously 
interferes with spontaneous cure, by the increasing, pressure which it pro- 
duces against the abdominal walls. In the herniated infant this, then, 
should be cast aside, the dressing for the navel string being held in position 
by adhesive straps or tapes passed around the body. After the desiccated 
remnant of the cord has dropped off nothing whatever in the way of a 
girth should be worn around the abdomen, but the garments, when the 
erect attitude is taken, should be all carried from the shoulders, thereby 
the feeblest possible action being given to the diaphragm and the organs 
of digestion. Occasionally we see one side of the scrotum occupied by a 
hernia before the testicle has descended. Congenital hernia is very rare 
in females. In the female the umbilical hernia is more common." 

Causes. — A calculus in any portion of the urethra or a phimosis or 
atresia of the urethral canal may cause powerful contractions of the ab- 

x For Umbilical Hernia see chapter on "Diseases of the Intestines." 

(361) 



362 DISEASES OF THE GENITAL ORGANS. 

dominal muscles, resulting in a hernia. Coughing, especially whooping- 
cough, frequently produces hernia. Constant straining efforts during con- 
stipation or when diarrhoea persists frequently end in hernia. 

Symptoms. — In male infants a tumor that is soft and round will be 
found in the scrotum. The testicle, although at times difficult to feel, is 
usually felt above or behind the swelling. This swelling consists of a loop 
of intestine; rarely the peritoneum descends with it. By placing the child 
on its back the swelling can easily be pushed into the abdomen through the 
abdominal ring. There is always a gurgling sound, which is characteristic 
of hernia. 

Diagnosis. — Hernia is frequently mistaken for hydrocele. Both hy- 
drocele and hernia are sometimes found in the same case. The following 
differential points are well worth noting : — 

Table No. 41. 
Hydrocele. Hernia. 

1. Translucent by transmitted light. 1. Is opaque. 

2. Always dull on percussion. 2. Always resonant. 

3. When reduction is possible the 3. The hernia passes back quickly 

fluid passes back slowly and and gives the characteristic 

noiselessly. gurgling sound. 

4. No impulse on coughing. 4. An impulse can be felt when 

patient coughs. 

5. The ring is empty. 5. The ring is filled with the neck of 

the tumor. 



Prognosis. — This is usually good. Children rarely have strangulation 
as we find it in adults. Most of the cases of hernia seen by me in children 
recovered with the aid of a properly fitting truss. At times nothing but an 
operation will cure the case. 

Treatment. — The diet should be regulated. If any apparent cause 
exists, such as prolonged diarrhoeas with tenesmus, constipation, or cough, 
the same should be treated. If a whooping-cough exists the proper treat- 
ment must be instituted before mechanical appliance is ordered. This 
consists chiefly in relieving the hernia with a truss. My own experience 
has been rather good by having a rubber sponge with a rough surface made 
to include the hernia. This should be held in place by the usual strap 
going around the body. The leather covered or the celluloid front pads 
are continually slipping; hence, not so well adapted for children. The 
hygiene should be well considered in a child. A truss on a diapered infant 
is a nuisance ; it cannot be kept clean ; hence, every nurse or mother should 
be instructed regarding the sensitive skin and the danger of causing irri- 
tation from moisture. Every mother should be taught to watch the infant 
when it cries or strains to prevent the truss from slipping. 



PHIMOSIS. 363 

Surgical Treatment. — With modern aseptic methods there is little 
or no risk in an operation. The success of the Bassini operation is so 
■uniform that I have seen dozens of children operated with no fatalities. 
For the details of this surgical method I would refer the reader to text- 
books on surgery. 

Hydrocele. 

"The testicle in its descent is surrounded by a serous membrane 
described by some authors as a serous pouch. "When this pouch fills with 
serum it is called a hydrocele. Xormally a few drops of serum are found, 
in the tunica vaginalis propria. Larger accumulations are met with in 
more than 10 per cent, of male infants, mostly on the right side, seldom 
on both. In the majority of cases there is no longer a communication 
with the abdominal cavity. When it remains a hernia may complicate 
the hydrocele and the diagnosis be more difficult, because the fluid is apt to 
return occasionally into the abdomen. Spontaneous absorption is not very 
rare, but suppuration is uncommon." 7 

Treatment. — Under aseptic precautions a sterilized needle or trocar 
should be introduced. By this means the serum can be removed. This 
simple method has frequently resulted in a cure. When the hydrocele fills 
up again the injection of a few drops of tincture of iodine or LugoPs solu- 
tion, or pure carbolic acid after the serum has been withdrawn, will usually 
prove successful. Operations are rarely required, although they are indi- 
cated if this milder form of treatment proves unsuccessful. 

Adherext Prepuce. 

Congenital agglutination of the prepuce and the glans penis is occa- 
sionally reported. The majority of cases seen are acquired conditions. 
Smegma frequently collects under the foreskin when the same is not prop- 
erly cleaned. 

Treatment. — "With a blunt probe an adherent prepuce can be loosened 
from the glans penis. The smegma should be removed and the parts 
lubricated with albolene or olive-oil. The mother or nurse should be 
instructed to oil these parts and thoroughly separate the prepuce so that 
new adhesions do not form. If this trouble recurs then circumcision is 
indicated. 

Phimosis (Circumcision). 

Phimosis is due to a narrowing or contraction of the prepuce so 
that the foreskin is prevented from being drawn back over the glans 
penis. A tight prepuce or an elongated prepuce is a constant source of 
irritation. Bed wetting is a very frequent symptom of this condition. 
There is an itching and an irritation which frequently lead to bad habits. 
The sensitive condition sometimes causes priapism, and this may lead to 



364 DISEASES OF THE GENITAL ORGANS. 

masturbation. Night terrors and insomnia are frequently caused by this 
condition. Phimosis is sometimes an exciting cause of chorea and various 
nervous diseases. 

Symptoms. — Such children invariably surfer with anaemia. They are 
peevish and restless and constantly irritable. The main symptoms are a 
series of irritations caused by the tight foreskin as outlined above. In 
exceptional instances strong, healthy children may not show any symptoms 
of this condition. 

The following case was seen by me in private practice: — 

A boy, 4 years old, has always been in apparently good health. He was 
breast-fed, well-nourished, and showed no evidence of rickets. His mother com- 
plained to me that the child had a "weak bladder," that he could not hold his urine, 
especially at night. He was restless and peevish, and tossed about in his sleep. 
On examination I found a phimosis existed. The prepuce did not slip over the 
glans, and the child cried as though in pain whenever the genitals were touched. 
I advised stretching the foreskin, and this was done every few days, with some degree 
of success, for the period of about three months. The child improved. When seen 
again about one year later the symptoms of nervousness, and restlessness reappeared. 
I then advised circumcision. With the assistance of Dr. John H. Wurthman, who 
administered chloroform, the prepuce was removed, the parts were dusted with 
europhen, and the wound healed per priman. The child improved gradually and is a 
good healthy child to-day. 

Treatment. — The treatment outlined in the case above described is the 
only one that should be used : First, stretching the prepuce; and, secondly, 
if this does not' afford relief, circumcision. 

Operation. — A simple method is to make an incision or cut the dorsum 
of the prepuce with a scissors. After this incision is made we invariably 
have another skin to divide, which is the mucous membrane. Unless tins 
is also incised we cannot expect relief from the constriction. As a rule small, 
cheese-like particles, called smegma, will be found, which must be cleaned 
away. Then follows the surgical treatment, such as checking haemorrhage, 
if the same is profuse. In rare cases one or more stitches may be necessary 
to control the bleeding. I invariably use a piece of sterile gauze saturated 
with MonsePs solution immediately after the operation, then dust the parts 
with europhen. Great care should be used to avoid infection from a case 
of diphtheria or erysipelas. It is safer to have a surgeon supervise or per- 
form the operation than to run the risk of infection. 

Paraphimosis. 

This is a condition caused by the swelling of the glans or by an abnor- 
mally small preputial orifice. 

Treatment. — Have the thumb and finger of one hand pressing on the 
glans ; with the other hand an attempt should be made to draw the prepuce 



CRYPTORCHIDISM. 365 

back in position. In some cases immersing the parts in very warm water 
for several minutes has served me very well. If the parts are very tender. 
a spray of ethyl chloride can be used with advantage before the attempted 
reduction. When the parts are very cedematous then puncturing the sur- 
face to relieve the serum will sometimes yield good results. At times sur- 
gical relief may be demanded. 

Hypospadias. 

The urethra sometimes opens on the under side of the penis. This is 
always a congenital condition. 

A case of this kind was seen be me in consultation with Dr. Julius Brandeis, of 
Xew York City. When I saw this infant it was three days old and apparently 
suffering pain. The bladder was distended, and the infant had not urinated, 
according to the history given, since it was born. An examination showed a 
hypospadias. The urethral orifice in the glans penis was absent. With the aid 
of diuretics and a warm hip bath the infant urinated. I have seen this child many 
times since. He is now able to walk and talk and suffers no inconvenience. 

The treatment is radical — by means of plastic surgery. 

Epispadias. 

In this condition the opening of the urethra is on the superior surface 
of the penis. It is less frequently met with than hypospadias. 

The treatment is distinctly surgical and requires a plastic operation. 

Cryptorchidism (Undescended Testicle). 

The testes usually descend into the scrotum during the ninth month 
of pregnancy. In some children the testicles may remain in the inguinal 
canal or even in the abdomen. 

Ralph C. was referred to me by Dr. W. Freudenthal. He was a well-nourished, 
healthy child. Was breast-fed and in apparent good health until two years ago. 
He suffered with cough, was a mouth breather, and snored at night, for the relief 
of which Dr. Freudenthal removed his adenoids. The child was brought to me for 
the relief of an irritable and restless condition. His mother stated that he scratched 
his nose and appeared to have a pruritus of the anus. The diagnosis of ascarides 
lumbricoides was made. While examining the child I found one testicle could be 
palpated in the scrotum and the other in the inguinal canal. By pressure on the 
abdomen it would descend. There were no symptoms directly attributable to this 
condition. 

Treatment. — If no irritation is caused then let it alone. If a false 
passage has been made which gives rise to pain, then the question of 
removal of the testicle may come up. The case then is distinctly surgical. 



366 DISEASES OF THE GENITAL ORGANS. 

Orchitis. 

An inflammation of the testicle is a rare condition in infancy. Cases 
have been reported where injury caused orchitis. In the article on "Mumps" 
orchitis is mentioned as a complication. The treatment consists in rest and 
ice-cold applications of lead and opium. Laxatives are indicated to open 
the bowels and thus help relieve the inflammation. 

Urethritis : Vulvo-vaginitis. 

Vulvo-vaginitis is a catarrhal infectious disease involving the female 
genital tract. It is divided into : — 

(a) Simple or Catarrhal; (b) Gonorrhceal. 

Simple Vaginitis. 

The normal urethra of both male and female children, also the vagina, 
frequently has a simple catarrh. The symptoms noticed are those of swell- 
ing, inflammation and a catarrhal secretion. 

Etiology and Bacteriology. — Normally the vagina contains a white 
diplococcus which is not decolorized by Gram. 

In simple catarrhal vulvo-vaginitis we have a white diplococcus which 
also is not decolorized by Gram. 

In gonorrhceal vulvo-vaginitis we have a white diplococcus which does 
not decolorize by Gram, and in addition thereto a yellow diplococcus called 
D. Flavus (Bumm). 

These germs are usually found in conjunction with other micro-organ- 
isms or with streptococci. They easily stain with a watery solution of eosin 
and counterstain with an alkaline aqueous methylene blue solution. 

The microscopical examination shows leucocytes, epithelium, and 
various micro-organisms; never gonococci. 

Symptoms. — The parts are usually sensitive to pressure. 

Children who are old enough complain of pain on urination, and also 
urinate very frequently. In very young children it is impossible, in fact, 
unnecessary, to make a vaginal or uterine examination. 

This disease may last for months, especially so if the body is in a 
subnormal condition. 

This simple catarrh affecting the vulvo-vagina is highly contagious, 
hence each case should be strictly isolated. 

Children so afflicted should sleep alone. 

Gonorrhceal Vaginitis. 

Gonorrhceal vulvo-vaginitis is frequently met with in practice. As a 
rule it occurs among poorer classes where families are crowded and un- 
sanitary. Frequently the infection is transmitted from the adult to the 



GONORRHCEAL VAGINITIS. 367 

child by sleeping in an infected bed. Cases are on record where a mother 
suffering with gonorrheal vulvo-vaginitis has infected her child while 
sleeping with it. 

Etiology. — The slightest abrasion of the skin will permit the entrance 
of the gonococcus. Cases have been reported in which a healthy person was 
infected by taking a bath in the same tub in which a person affected with 
gonorrhoea had bathed the day previous. It is a well-known fact that the 
gonococcus will live twenty-four hours, hence these germs will persist in the 
tub and can transmit infection. For this reason a separate tub should 
be procured while gonorrhceal disease exists. 

Bacteriology. — Gonorrhceal vaginitis is caused by the presence of the 
gonococcus. It is necessary, however, to subject the gonococcus described 
by Neisser to the Gram method of staining. The diplococcus found in the 
normal urethra can easily be differentiated by subjecting the same to the 
Gram stain. Normally the gonococcus has never been found in the vulvo- 
vaginal tract or in the normal urethra. The gonococcus can easily be 
stained with a 2 per cent, alcoholic methylene blue solution. 

Mode of Infection. — Direct transmission of infected matter from adults 
to children has been known to occur. Infected clothing, especially bed 
linen, has transmitted this disease. 

In rare instances the infection has taken place directly during the 
sexual act. There is a popular superstition that when an adult male has 
gonorrhoea he will be cured by raping a healthy child. An instance of this 
kind has occurred in my practice. 




Fig. 111. — Gonococcus. ( Gonorrhoeal Pus.) Stained one-half minute 
with methylene-blue. a, Free in groups, b, Enclosed in pus cells, Leitz 
ocular I. Oil imersion 1 / 12 . ( Lenhartz-Brooks. ) 



368 DISEASES OF THE GENITAL ORGANS. 

A little girl, 6 years old, apparently healthy, was infected by an adult suffering 
with gonorrhoea. She suffered continuously for over four months until brought to 
me, when her vulva, vagina, and urethra were one mass of inflammation. There 
was a greenish-yellow discharge. The bacteriological examination showed diplococci 
in the leucocytes. 

The child Was put to bed and a sterilized pad applied over the genitals. This 
pad was changed every four hours. A sitz bath of 1 to 2000 warm bichloride was 
ordered morning and evening, lasting twenty minutes. A vaginal injection of 10 per 
cent, argyrol solution was given immediately after each bath. Internally iron 
was given. The discharge continued eleven days and everything seemed well. A 
reinfection evidently took place four days after having stopped the active treatment, 
as the discharge appeared with renewed vigor. The child was again carefully 
treated with astringents. The discharge persisted for three months, when it was 
finally cured. 

Complications. — The Eye: The danger of transmitting gonorrhceal 
infection by the hands from the genitals to the eyes must always be re- 
membered. That this form of infection is not without danger is well 
known. At the Riverside Hospital in the scarlet fever wards, during the 
summer of 1902, I saw a child that was totally blind, the result of a gonor- 
rheal infection. 

The Joints. — We occasionally meet with symptoms of inflammation 
involving one large joint; this is called monarthritis. An inflammation 
of this kind usually means gonorrhceal infection. 

The Heart. — When the gonococcus enters the circulation it frequently 
attacks the valves of the heart. Valvular lesions are similar to joint lesions ; 
hence we must not be surprised to see cases reported in which a gonorrhoea 
started at the genital tract, entered the circulation, and involved the heart. 
A case of this kind was reported by Leyden, of Berlin. 

Pyelitis caused by an extension of this infection from the urethra may 
end fatally. An infection may spread from the vagina into the uterus and 
set up a salpingitis and end fatally. On the other hand, this disease, if 
neglected, may assume a chronic tendency and cause sterility, so that a 
guarded prognosis should be given in every case until the infection is modi- 
fied and the outlook is good. (Read article on "Pyelitis.") 

Vicarious Menstruation. 

Some children have a periodical nosebleed, recurring every three or 
four weeks. In some cases there is a considerable flow of blood, lasting 
between two and five days. In making the diagnosis it is important to 
exclude all diseases due to local causes, such as polypus or haemophilia. 
In one case seen by me (see chapter on "Syphilis") fatal haemorrhage 
resulted in a case of congenital syphilis. 

The cause is unknown. 

Treatment. — The body should be strengthened and iron given inter- 
nally. A change of air to the seashore or mountains will strengthen the 
body and frequently relieve this condition. 



MENSTRUATION. 369 



Menstruation Precox. 



We occasionally see girls from 6 to 10 years of age with regular men- 
struation. Literature records numerous cases of children from 2 to 5 years 
of age with regularly recurring menstruation. Such menstruation lasts sev- 
eral days or in some instances several hours. As a rule, such children are 
delicate, tuberculous, or syphilitic. 

Symptoms. — There is usually pain in the abdomen similar to colic, 
restlessness, and a series of nervous symptoms. Such children are hard 
to please. 

Diagnosis. — It is necessary to exclude local causes, such as papil- 
lomatous or polypoid excrescences. I have previously referred to haemophilia 
and to syphilis as a possible cause. Local causes, such as masturbation or 
traumatism, must be excluded. As a sequela to acute infectious diseases, 
we frequently have vaginal catarrh. This discharge may sometimes be 
mixed with blood. The diagnosis depends on the regularity of the periods, 
recurring every three or four weeks. 

Treatment. — Warm, demulcent drinks and the avoidance of cooling 
liquids. The child should be kept in bed and warmly dressed. 

If the bleeding is very profuse, then 5 to 10 drops of fluid extract of 
ergot (Squibb's), or hydrastinin hydrochlorate, 1 / 10 to 1 / 20 grain, three 
times a day, may be given. An ice-bag over the abdomen will frequently 
relieve severe pain and check profuse bleeding. 



24 



CHAPTER VII. 
DISEASES OF THE KIDNEY AND BLADDER. 

The Kidney. 1 

The kidneys of an infant are proportionately larger than in adult life. 
They are also situated lower than in the adult. The large size of the liver 
in infancy is the reason for the difference in position of the right and left 
kidney. The right kidney is situated lower than the left. The suprarenal 
capsules are much larger than in the adult. After the second year the 
kidneys assume the position usually occupied by the adult kidneys. 

Acute Nephritis (Acute Glomerulo-Nephritis ; Acute 
Bright's Disease). 

Primary nephritis is by no means a rare condition in children. In 
the majority of text-books nephritis is described as the complication of 
infectious diseases. It is true that it is most often seen following the 
acute infectious diseases. In primary nephritis the source of infection is 
sometimes hard to trace. Pathogenic bacteria can reach the kidneys through 
the circulation and thus set up nephritis. 

Etiology. — The influence of exposure, "taking cold/' must be looked 
upon as an associated factor in the causation of this disease. 

Comby 2 explains this as follows: — 

In the absence of a specific process, such as scarlatina, diphtheria, etc., 
we are led, upon the occurrence of acute simple nephritis, to suspect the 
influence of cold. The action of cold, however, is not always direct. In 
nephritis, as in pneumonia, cold alone does not cause the disease. It en- 
feebles the organism, increases its receptivity, augments the virulence of 
microbes, and opens the gates by which they enter. Children carry within 
themselves, in the mouth, pharynx, and nasal passages, various microbes, 
which only await an opportunity of wakening into activity. This opportu- 
nity is afforded them by the impression of cold. 

The sore throat which so often precedes nephritis constitutes a first 
step toward the invasion by pathogenic microbes. The epithelial barrier 
is broken down, the micro-organisms reach the lymphatic glands, where 
they are often arrested or may continue their progress, passing into the 



x The urine, its physiological and pathological condition, is described in detail 
in the chapter on "Urine," Part XII. 

2 "Nephrite Aigue Simple des Enfants," par le Dr. J. Comby, La MGdecine 
Moderne, December 1, 1897. 

(370) 



ACUTE NEPHRITIS. 371 

circulation, and finally excite a distant inflammation which, may be, accord- 
ing to circumstances, a pneumonia, an endocarditis, or nephritis, etc. 

In some cases an apparently most trival angina becomes complicated 
with swollen cervical glands, and, subsequently, with acute nephritis, etc. 
Cases have been described as glandular fever, or, in other words, acute 
adenitis, symptomatic of pharyngeal infection, in which nephritis has 
developed, superadded to the original disease, which it finally survives. 
These complications are not fortuitous, but are linked together in strict 
sequence. 

Pathology. — Inflammation of the kidney in a large majority of cases 
commences as a glomerulo-nephritis, the delicate walls of the capillaries, 
and their equally delicate epithelial investment being the earliest to suffer; 
and instead of the non-albuminous urine, one laden with albumin escapes. 
If the inflammation still progresses, corpuscles, especially the red, make 
their way out and produce smoky or bloody urine, the naturally high pres- 
sure in the glomerulus no doubt greatly facilitating the diapedesis. The 
casts which may now appear consist for the most part of fibrin, of red and 
white corpuscles, and of renal debris, moulded in the tubes. 

The glomerular disturbance is followed by that of the rest of the vas- 
cular net-work and of the gland cells. The latter become swollen and 
"clouded," and are readily detached. The swollen cells may occlude the 
lumen of the ducts and press upon the vascular tissue without. Or the 
capillaries are congested and exudation swells the intertubular tissue. In 
any case the tissue is enlarged and softened. Sometimes during life the 
signs of nephritis are well marked, but after death the anatomical lesion 
appears very slight; in these cases comparison with a normal kidney, both 
to the naked eye and under the microscope, is invaluable,, as then some 
change can usually be detected. 

The kidney of typhoid and diphtheria serve as examples, although 
there are numerous acute specific diseases which are accompanied by ne- 
phritis and albuminuria. The glomeruli are enlarged, owing to swelling 
of the interstitial substance and to engorgement of the capillaries and 
often swelling of the endothelial cells; there is in addition an increase 
in the number of nuclei in the glomeruli. Bowman's capsules may be 
slightly distended, their endothelium swollen or proliferating, and the 
spaces occupied by fibrin or white or red corpuscles. There may be an 
increase in corpuscles around the roots of the glomeruli. The tubules may 
be dilated, the epithelium swollen and granular, or there may be some 
proliferation. Casts are numerous, though usually hyaline; they may 
consist of blood. Small haemorrhages are frequent, especially in diph- 
theritic kidneys. 

Acute nephritis in the new-born has been described by Jacobi. 1 



1 New York Medical Journal, January, 1896. 



372 



DISEASES OF THE KIDNEY AND BLADDER. 



Symptoms. — Gastric disturbances, such as vomiting, are very fre- 
quently noted. As a rule premonitory symptoms are absent. Nephritis fre- 
quently begins with fever, loss of appetite, headache, and general malaise. 
Swelling of the face is sometimes the first sign of trouble. 

The urine is always scanty and sometimes contains red blood-corpus- 
cles, leucocytes, and casts. The urine shows the evidence of acute renal 
congestion and is always albuminous. In grave cases there are frequent 
efforts to pass urine, and these attempts are attended with pain. With great 
difficulty the child expels a few drops of dark colored urine. According 
to the severity of the case these symptoms subside after a period varying 
from ten to thirty days. Irregularity of the pulse is frequently noted, and 
should always be looked upon as an evidence of toxaemia. It is a grave 
symptom. 





flH 


■ fiw^B^v 






r^^s^^ 


4 _ jmm* s& 






. .. • . 



Fig. 112.— Nephritis Complicating Diphtheria. Case seen by me 
at the Willard Parker Hospital. (Original.) 

The action of the heart should be closely followed in every case of 
nephritis. 

Prognosis. — This is usually good. If treatment is neglected in an 
acute nephritis, a chronic nephritis will result. In rare instances a general 
toxaemia may cause convulsions and death. 

Nephritis a Complication. — This disease may accompany or follow 
scarlet fever or diphtheria. It is also occasionally seen in most infectious 
diseases such as typhoid, measles, varicella, pneumonia, influenza, malaria, 
meningitis, and empyema. 

In a study of gastro-enteritis made by Baginsky, the frequent asso- 
ciation of nephritis was noted. This author found that the bacterium coli 
could frequently cause acute nephritis. 

Elaine K., a girl, 5 years old, had vomiting, followed by an eruption of scarlet 
fever covering the entire body. The rash was distinct for three days and then 
faded. The physician in attendance said it was a case of mild scarlet fever. The 



SECONDARY NEPHRITIS. 373 

child was up and about during the second week following the eruption. The stomach 
was not carefully guarded, as the child was given a too liberal diet. On the twelfth 
day from the beginning of her illness she suddenly had what the family called a 
sinking spell. Evidences of heart weakness were noted. Two days later, or on 
the fourteenth day of her illness, she was again put to bed. At this time she com- 
plained of pains in her joints. The glands of the neck were swollen. The urine 
was somewhat scanty. On the seventeenth day she had three very severe convulsions. 

Owing to the careless management of this case, the family discharged the 
first attending physician. Later the family called Dr. M. Pechner, who saw the 
severe toxaemia and noted the anuria. I saw this case twenty-one days after the 
beginning of the disease. The diagnosis of nephritis was easily made. Hardly an 
ounce of urine was passed during the day. The child was (edematous and had the 
waxy appearance seen in acute nephritis. The heart sounds were muffled. The 
pulse-rate was slow and irregular. The temperature was very slightly elevated, 
although a severe myocarditis existed. The child was placed in bed, under the care 
of two trained nurses. 

Treatment. — Hot packs, diaphoretics, and diuretin, in doses of 5 to 20 grains, 
three and four times a day were given. Hot saline colon flushings at a temperature 
of 115° F. were ordered to stimulate diuresis. A bland liquid diet aided by liquids, 
lemonade, and cream of tartar, formed the main treatment. The child made a 
brilliant recovery. There were no complications after the disappearance of the 
nephritis. 

Secondary Nephritis. 

Secondary nephritis, following the acute infectious diseases, can best 
be studied by taking the type most frequently met with, namely, post-scar- 
latinal nephritis. (See chapter on "Scarlet Fever" for a complete descrip- 
tion of this condition. Note also the microscopical appearance of the 
urine in the same chapter, page 616.) 

Treatment. — Cream of tartar lemonade, a teaspoonful of cream of 
tartar, added to a tumblerful of ordinary lemonade, and sweeten. This 
should be given freely. Another drug that has served me very well is 
diuretin; this should be administered in doses of from 3 to 15 grains, 
depending on the age. This can be repeated every three or four hours, 
depending on the severity of the case. When diuretin is not well borne by 
mouth, I give it in the form of suppositories per rectum. 

The following has served me very well as a diuretic in nephritis when 
the urine was scanty : — 

B Potass, citrat 2% drachms 

Ext. buchu. fluid 2% drachms 

Ext. uva ursi fl 1 drachm 1 scruple 

Syr. limonis 2 ounces 

Aqua q. s. ad 4 ounces 

Sig. : Teaspoonful every two or three hours. 

Calomel or podophyllin, in small doses, 1 / 20 grain, repeated every two 
or three hours, is sometimes valuable in this condition. Lithia water and 



374 DISEASES OF THE KIDNEY AND BLADDER. 

the alkaline waters are generally indicated. An infusion made by scalding 
the ordinary parsley root (rad. petrosilini), using about one teaspoonful 
of the chopped -root to a teacupful of boiling water, strain and sweeten. 
This can be given in large quantities whenever the child is thirsty. Sweet 
spirit of niter in doses of % teaspoonful, gradually increased, for a child 
1 to 5 years old, and repeated every three hours, is a safe and efficient 
diuretic. 

Jaborandi or its alkaloid, pilocarpine, are frequently advised as diu- 
retics. I have frequently seen such cardiac depression follow their admin- 
istration that I invariably warn against their use. In conclusion, I desire 
to lay great stress on the weakness of the heart frequently noticed after 
the administration of the hot-air bath. In one instance where I was called 
into consultation, the child died during the administration of such a bath. 

Perinephritis. 

An acute inflammation involving the cellular tissue which surrounds 
the kidney, as a rule terminating in suppuration. Some cases may resolve 
without suppuration. 

Etiology. — It may be associated with or due to suppurative process in 
the kidneys. It is also found in tubercular conditions. The most frequent 
cause undoubtedly is traumatism. Idiopathic conditions are frequently a 
distinct factor. 

Perinephritis is not of frequent occurrence. Townsend gives the fol- 
lowing statistics : "Nieden, in 1897, found records of 166 cases. Twenty- 
three of these were under 15 years of age, the youngest being five weeks 
old. In 1880 Gibney reported a total of 28 cases; the ages varied from 
l!/2 to 15 years. In 16 there was suppuration; in 12, no suppuration. In 
19 cases no cause was found; in 8 cases a cause was given. Fenwick re- 
ports 76 cases: 4 children under 10 years, and 9 between 10 and 20 years, 
the youngest being fourteen months old. Kustre makes a report of 230 
cases, 24 under 10 years of age, 17 between 10 and 20 years. Johnson, in 
an experience of nine years in Eoosevelt Hospital, saw but one case in a 
child, a perinephritic abscess in a boy of 10 following a fall, not complicated 
by a kidney lesion. Israel, in a report of 43 cases, speaks of one in a 
patient 12 years old." 

Out of 3689 patients treated in the outdoor department of the Chil- 
dren's Hospital for the Eelief of the Euptured and Crippled, in New York, 
during 1894-1903, only 6 cases are reported by Townsend. 

Pathology and Bacteriology. — As a rule, 80 per cent, of the primary 
cases terminate in abscess. In secondary cases an abscess is always found. 
The pathological condition is the same as is found in every acute inflam- 
mation. The pus contains either the streptococcus, the staphylococcus, or 
colon bacillus. In rare instances the pneumococcus and the typhoid ba- 



PERINEPHRITIS. 375 

cillus are present. In tubercular manifestations the tubercle bacillus will 
be found. 

Symptoms. — A child that has been in good health will suddenly de- 
velop pain in the region of the kidney near the vertebra. The pain extends 
downward and simulates sciatica. Moving the body increases the pain; 
hence the spine is generally rigid. For this reason alone many cases are 
mistaken for Pott's disease. There will also be fever, the temperature 
ranging between 102° and 104° F. If the child is old enough to complain, 
then chills will be noted. In the ileo-costal region there is usually a pal- 
pable tumor. Children so afflicted will refuse to walk on the affected side, 
and will limp. They describe the pain as though it were in the groin, in 
the hip, or sometimes in the knee-joint. If pyelitis complicates, the urine 
will contain pus. Owing to the passive condition there is constipation. 

A. B., 9 years old, complained of pain in the groin and also in the back on the 
left side. He limped and could not stand on his left leg. He complained of chills 
and his temperature rose to 103° F. He urinated very frequently. After a careful 
examination the urine was found to contain nothing abnormal. The boy was put to 
bed. The bowels were flushed. Owing to small roseolar spots which appeared, 
typhoid fever was suspected. The blood reaction for Widal was absent. The urine 
gave no diazo reaction. The pain increased, and after ten days of expectant treat- 
ment a swelling was noted in the loin. 

This swelling gradually increased in size until it was as large as a hen's egg. 
A surgeon was called, who diagnosed perinephritis. An incision was made and two 
ounces of pus liberated. The wound was packed with sterile gauze, and, with rest, 
iron, and strychnine internally, the boy recovered in about five weeks. 

Diagnosis. — This condition may be confounded with hip-joint disease, 
but hip-joint disease develops very slowly and has a tendency to become 
chronic. The symptoms, while very similar in perinephritis, develop sud- 
denly from within a few days to a few weeks, and recovery may occur within 
a few weeks after the first symptoms are noted. In hip-joint disease the 
symptoms extend over months and years. 

The Blood. — An important diagnostic point is the increase in the num- 
ber of leucocytes, such as we find in purulent conditions in other parts of the 
body. In tuberculosis there is no leucocytosis unless sepsis exists. 

Prognosis and Course. — Primary perinephritis runs an acute short 
course of a few weeks and usually terminates favorably. Gibney reports 
28 cases, all of which recovered. 

Treatment. — Rest in bed and a warm poultice over the affected area to 
hasten suppuration. The abscess should be treated on strict surgical prin- 
ciples. No time should be lost when fluctuation is felt, owing to the danger 
of pus burrowing into the peritoneal cavity. 

■Restorative treatment, such as diet, fresh air, iron, and codliver-oil, 
should form the basis of the building-up process. 



376 DISEASES OF THE KIDNEY AND BLADDER. 



Pyelitis ( Pyelonephritis ) . 

This condition is rarely met with in practice. Literature records 
isolated cases. Monti, of Vienna; Baginsky, Steffen, and Holt are among 
those who have reported cases of this kind. 

Causes. — Pyelonephritis occurs at all ages, but is more common in 
adult males than in the young. The exciting causes in adult males are 
stricture of the urethra, renal calculi, prostatic diseases, and infection by 
means of dirty catheters. That girls seem to have been favored by this 
disease can be seen by referring to the literature; thus Professor Baginsky 
reports three cases, all girls, in the Deutsch. med. Wochenschrift, 1897, 
No. 25, which he discussed at the Verein fur innere Medicin in 1897. 
In these three cases the author was able to grow a culture of the bac- 
terium coli from the urine. He believes the bacterium coli to be the true 
etiological factor in this disease. In these three cases there were marked 
gastroenteric disturbances ; in two cases, membranous enteritis and obstinate 
constipation. In my case here reported there was severe constipation requir- 
ing constant treatment. 

Baginsky further maintains that the bacterium coli can enter the 
kidneys through: first, the circulation of the blood; second, the lymph 
channels; third, the urethra. 

Escherich, 1 Finkelstein, 2 and Trumpp 3 have reported a series of cases 
in which cystitis was found associated with intestinal affections. Baginsky 
reports two cases of pyelonephritis which could be attributed to the method 
of using gymnastics during orthopaedic treatment for the correction of con- 
genital dislocation of the hip-joint. In connection with the exercises a 
direct invasion of the bacterium coli from the urethra to the bladder could 
be traced. Other authors, as Posner, believe that external influences have 
no bearing on the etiology, and that the infection takes place from within 
th6 body. It is a well-known fact that gonorrhceal vulvo-vaginitis, espe- 
cially when it occurs in little girls, can cause either pyelitis or pyelone- 
phritis. This is termed the ascending variety. Chronic occlusion of the 
ureter may be followed by a pure pyelonephritis, without preceding cystitis, 
when the exciting agents of inflammation, which are present in the cir- 
culating blood, are eliminated through the kidneys and collect in the stag- 
nating urine in the pelvis of the kidneys. Experimentally this disease can 
be produced in rabbits by ligating the ureter and injecting either bacterium 
coli or pyogenic cocci directly into the pelvis of the kidney or into the 
veins. 



1 Mittheil. d. Vereins der Aerzte in Steiermark, 1894. 

2 Finkelstein, Jahrbuch f. Kinderheilkunde, Band xliii, page 148. 

3 Trumpp, Ibid., Band xliv, page 249. 



PYELITIS. 



377 



Pathology. — Increased pressure in the tubules from obstruction to the 
escape of urine; reflex irritation of the kidney; the presence of septic 
matter in the pelvis of the kidney and possibly in the lower parts of the 
tubules. Most frequently these three causes act, in succession and in the 
above order, in the same case. As a rule, when acting singly, increased pres- 
sure from obstruction will produce hydronephrosis; reflex irritation will 
excite one of the transient or congestive types of urinary fever; and septic 
matter in the pelvis of the kidney will cause acute or suppurative pyelone- 
phritis. Increased urinary pressure alone often produces chronic inter- 
stitial nephritis as well as sacculation and dilatation of the kidney; but it 
rarely, if ever, causes acute or subacute interstitial nephritis. Decompo- 



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Fig. 113.. — Fever Curve in Pyelonephritis. (Original.) 



sition of urine in the bladder or pelvis of the kidney may produce suppura- 
tive changes in the kidneys. If the dilatation of the kidney is not compli- 
cated by suppurative pyelitis hydronephrosis results. If it is so compli- 
cated, pyonephrosis is produced. Ivlebs and others believe that bacteria have 
migrated to the pelvis and calices of the kidney, there to produce their 
destructive changes, hence the names of parasitic nephritis and pyelo- 
nephritis as proposed by Klebs. 

Lindsay Steven in a thesis on the pathology of the suppurative inflam- 
mations of the kidney, published in the Glasgow Medical Journal, Septem- 
ber, 1884, corroborates Klebs's view and expresses a decided opinion that 
micro-organisms are at the root of the infection, and cause the formation 
of multiple renal abscesses consequent on diseases of the lower urinary 
passages. He, however, considers that there are two ways whereby the par- 
ticular virus gains access to the kidney and sets up suppuration in many 
different points, namely : first, by means of the uriniferous tubules, and 
second, by means of the lymphatics of the ureter and kidney. 



378 DISEASES OF THE KIDNEY AND BLADDER. 

Steven shows that the lymphatics, quite independently of any other 
channel, may form the pathway of the virus from the bladder to the kidney. 
He admits that the two ways may be more or less combined in many cases ; 
so that multiple miliary abscesses may originate in the same kidney, partly 
by the invasion of micrococci along the ureter and uriniferous tubules, and 
partly by their inroad along the lymphatic tracts of the kidney. 

Traube and others who do not think that the bacteria themselves 
excite the inflammation, consider that these organisms cause the decom- 
position of urea into carbonate of ammonia and that this in turn excites 
the inflammation of the mucous membrane of the kidney. 

Prognosis. — The prognosis is grave and depends on the toxin caused 
by the presence of the pus. The outcome of the case depends on the dis- 
appearance of the pus in the urine, which must be watched for at times. 

Treatment. — A child suffering with pyelitis should be put to bed in 
a cool room having plenty of fresh air and sunlight. 

Dietetic treatment such as milk with some alkaline water is useful. 
N~'o solid food should be permitted. Whey, soups, broths, and fruit juices 
may be given. Oranges and lemons, owing to their diuretic effect, are 
valuable. The internal use of Eoncegno water or Wildungen water is also 
recommended for its diuretic effect. 

Diuretin, in 2 to 10-grain doses three times a day, is sometimes useful. 
Urotropin is a very valuable drug and serves both as a diuretic and as an 
internal antiseptic. 

The Bladder. 

The bladder takes up almost all of the lower portion of the abdomen, 
as it is capable of marked distention when filled. To make proper physical 
examination the bladder should be emptied by catheter. 

Eotch refers to a distinguished laparotomist who did not empty the 
bladder of a child before operating for an appendicitis; on opening the 
abdominal cavity he cut directly through the walls of the bladder. The 
urine flowing out reminded him of his failure to appreciate the fact that 
in early life the bladder is essentially an abdominal organ. 



Ectopia Vesica Congenitalis (Extroversion of the Bladder: 
Exstrophy of the Bladder). 

This anatomical peculiarity is due to deficient closure of the neutral 
laminae causing this hiatus of the abdominal wall in some cases. "The 
lower part of the abdominal wall, from the umbilicus or its neighborhood 
downward, may fail to close, and, coupled with this, there may be deficiency 
of the anterior wall of the bladder." This constitutes extroversion, some- 



ECTOPIA VESICA CONGENITALIS. 



379 



times called exstrophy of the bladder. The ureters are plainly visible and 
the urine dribbles continuously. The child is constantly wet and excoriated 
from the moisture and its irritation. The urine is passed in distinct jets 
or streams, and is especially noticeable when the child cries or strains. 

The following case was presented by me to the children's clinic of the 
New York Post-Graduate Medical School and Hospital. 1 

A female infant, 1 year old, was seen by me. She was breast-fed and well- 
nourished. Soon after birth the mother noticed a constant dribbling of urine and 
attention was directed to a swelling situated in the region of the umbilicus. The 




Fig. 114. — Exstrophy of the Bladder, and Prolapse of Anus. (Original.) 



diagnosis of exstrophy of the bladder was made. A bland ointment was prescribed 
to relieve the excoriation from the constant dribbling of urine. As this case 
required a plastic operation it was referred to Dr. Carl Beck, at the St. Mark's 
Hospital, for surgical treatment. 



l This case was also presented by me at the Scientific Society of German Phy- 
sicians held at the residence of Dr. A. Jacobi about ten years ago. 



380 DISEASES OF THE KIDNEY AND BLADDER. 

A child in this condition should not be operated upon until 3 or 4 
years of age. 

Indicanuria. 

A trace of indican is found in the urine in health. A very strong 
indican reaction should always be regarded as abnormal and hence it is 
pathological. As indican is derived from indol it signifies a product of 
decomposition and denotes putrefaction of the proteins. It has also been 
found in empyema and in extensive suppurative processes where putrefac- 
tion abounds. Stagnant fseces, constipation, chronic intestinal indigestion, 
and some forms of putrefactive diarrhoea will give a strong indican reaction. 
Herter has reported the presence of indican in the urine in cases of 
epilepsy at the time of the seizures. In the early stages of typhoid fever, 
when the diagnosis is doubtful, the presence of a diazo reaction and the 
absence of indicanuria is a valuable aid in establishing the diagnosis. 

Eliminative treatment such as cleansing the gastro-intestinal tract, 
besides reducing the amount of meat and eggs, will relieve an excess of 
indican (see articles on "Intestinal Indigestion"). 

Acetonemia. 

This condition is caused by the faulty assimilation of food. It is 
usually found in children over 2 years of age, and occurs most frequently 
in children between the ages of 5 and 12 years. 

Symptoms. — Fever ranging between 102° and 105° is usually present. 
There is a correspondingly increased pulse rate. Some cases show nausea 
or singultus, anorexia, and intense thirst. Some complain of headache, and 
vomit. The characteristic sweet vinegar odor, "acetone breath," is present.. 
The urine contains acetone and usually indican. The eyes appear sunken. 
The child presents a typhoidal appearance. 

Treatment. — The diet must be restricted for twenty-four or forty-eight 
hours to skimmed milk or weak tea, strained soups, and fruit juices. 

Large doses of soda bicarb, are indicated. In severe forms of acetonuria 
typhoidal symptoms may be present, and, if so, an intravenous injection 
of soda bicarb, is indicated. 

The prognosis, as a rule, depends on the restriction of the diet, and on 
the amount of soda bicarb, given to counteract the effect of this poison. The 
injection of a 10 per cent, soda bicarb, solution into the colon will also aid 
in modifying this condition. 

Acetonuria. — Diacetonuria. 

We are indebted to Baginsky for a careful study of this condition. He 
found that it was present in children during epileptic attacks. It is also 



PYURIA. 381 

found during the height of fever. He.does not believe that acetonuria bears 
any relation to the nervous symptoms which accompany fever. 

Diacetonuria is very common during high fever. It is more frequently 
present than acetonuria. Binet, quoted by Holt, found diacetic acid in 
69 out of 150 examinations in febrile diseases, chiefly in scarlet fever, 
measles, and pneumonia. 

Pyuria. 

When pus is found in the urine, it gives a reaction like albumin, namely, 
coagulates on boiling. Pus cells, however, can be seen only by placing a 
drop under the microscope, using low power. While pus usually indicates 
pyelitis or pyelonephritis, it may exude from the ureters, the bladder, the 
urethra, or the vagina. 

Tubercular or suppurative conditions affecting the spine associated with 
caries of the spinal vertebrae may drain into the urinary tract. It is impor- 
tant, therefore, to locate the cause before treatment is commenced. 

Pus from the bladder is always mixed with mucus. It may be acid or 
alkaline in reaction. The urine containing pus due to pyelitis has an acid 
reaction. If the child is old enough, a cystoscopic examination should be 
made. This will aid in excluding the bladder and the ureters as a possible 
source of the pus. 

Treatment. — Demulcent drinks, alkaline waters, such as the Wildungen 
water, have a mild, diuretic effect. Salol and urotropin are the best drugs 
in doses of 2 to 5 grains three times a day. Milk, cereals, and fruits should 
be ordered; meat and eggs prohibited. 

Lordotic Albuminuria (Orthostatic Albuminuria). 

Heubner has directed attention to the presence of albumin in the 
urine when children are standing erect. The albumin disappears when the 
child assumes a horizontal position ; hence albumin will be present by day, 
and will disappear in the urine voided at night. 

Jehle, of Vienna, in his monograph published in 1909, has studied this 
question more closely, and finds a different cause for the presence of the 
albumin in the urine. He finds that when lordosis is present, and in con- 
sequence the lumbar vertebrae offend the kidneys by displacement or pres- 
sure, albumin will at once appear in the urine. That this is no theory 
he shows by producing an artificial lordosis. When in the dorsal position 
albumin will be found in the urine and disappear when such pressure is 
removed. This presence of albumin is found in normal kidneys in which 
no previous scarlatinal or other forms of nephritis have existed. It is, 
therefore, a mechanical type of albuminuria which can be made to appear 
during the lordosis and to disappear when the lordosis is corrected. 



382 DISEASES OF THE KIDNEY AND BLADDER. 

Hematuria (Bloody Urine). 

Hematuria is known by the presence of red blood-cells in the urine. It 
may be due to local irritation or to systemic disease. It is therefore fre- 
quently met with during the course of a severe attack of acute nephritis 
complicating scarlet fever. A case of this kind is reported in the chapter 
on "Scarlet Fever." I have frequently seen haematuria during the course 
of the hemorrhagic form of diphtheria while on duty at the Willard 
Parker Hospital. I have also seen haematuria in scurvy. 

It is important to remember that irritation caused by a calculus in 
the kidney, the ureter, or the bladder may give rise to bloody urine. Direct 
injury to the kidney or bladder, or a tumor in the bladder, may cause 
bloody urine. 

The general causes frequently met with are .haemorrhagic diseases of 
the new-born; the blood dyscrasiae, such as scurvy, purpura, and hsemo- 
philia; and infectious diseases, particularly malaria, typhoid, variola, scar- 
let fever, and influenza. In most of these cases the amount of blood passed 
is small. When it is large it may appear in the urine as clear blood or as 
clots, or it may impart simply a reddish or smoky color to the urine. The 
color, however, is not a reliable guide; the best of all is the microscopic 
examination. For a simple chemical test guaiacum may be used (Holt). 

It is a difficult matter to discover the source of blood in some cases, 
although large haemorrhage is more apt to result from the kidneys than 
from the bladder. To differentiate we must rely on the presence of casts 
from the renal tubules; thus we can satisfy ourselves of the renal origin 
of the haemorrhage. 

The prognosis depends on the amount of haemorrhage and the general 
condition of the child. It should always be regarded as a bad symptom, 
although not necessarily fatal. 

Treatment. — The application of an ice-bag or dry cups over the region 
of the kidneys, rest in bed, Squibb's ergot, gallic acid, 3 to 10 grains, 
repeated every three or four hours, or the fluid extract of hydrastis cana- 
densis, in 3- to 10- drop doses, for a child 2 years old, repeated every three 
or four hours, will sometimes do good. 

The food is best given either cool or very cold. If the child is old 
enough, small pieces of cracked ice or ice cream may be given until the 
blood disappears. 

HEMOGLOBINURIA, 

Instead of blood cells in the urine this condition manifests itself by 
the presence of Hood pigment in the urine. Sometimes the urine is 
blackish. Albumin may frequently be found associated with haemoglobin. 
The pathology of this condition is at present unknown. It is very easy to 



DIABETES INSIPIDUS. 383 

recognize the pigment under the microscope. It can also be noted by 
Heller's test. The most positive method of diagnosis is the spectroscope. 

Not infrequently this condition is met with in the infectious diseases, 
which is evidently due to the effect of the toxins generated by the specific 
micro-organisms causing these diseases. When an irritant poison, such as 
carbolic acid, is swallowed, this condition is encountered and recognized, 
clinically, by the familiar term "smoky urine." 

Paroxysmal hemoglobinuria is occasionally met with in childhood. 
It is usually associated with syphilis. Other cases have been reported. 1 

Glycosuria. 

The appearance of sugar in the urine is not necessarily pathological. 
Grosz published a series of investigations dealing with this condition. He 
found that glycosuria occurs in nursing infants who have either functional 
or inflammatory disturbances of digestion. He did not see it in perfectly 
healthy nursing infants. The sugar found in the urine reacts to Fehling's 
test; it does not respond to the fermentation test. The polariscope shows 
that it has the power of dextrorotation, so that the sugar present is pos- 
sibly milk sugar or one of its derivatives. 

Artificial glycosuria can be produced by administering a large quan- 
tity of milk sugar in the food; hence it may be presumed that the sugar 
excreted in the urine is simply the excess of what could not be absorbed in 
the system. 

Glycosuria was frequently noted by me in the urine of children fed 
exclusively on Nestle's food. When this form of feeding was discontinued, 
the glycosuria disappeared. These cases could therefore be classified under 
the head of dietetic glycosuria. 

Diabetes Insipidus (Polyuria). 

This is a very rare condition in children. Its etiology is obscure, 
although males are more frequently attacked than females. Little is known 
of its origin excepting that traumatism involving the brain has been known 
to be followed by diabetes insipidus. 

The pathology of this disease is unknown. It is supposed to be a 
neurosis, but whether the lesion is near the fourth ventricle, or whether its 
seat is in the renal nerves, has not yet been determined. 

Symptoms. — Excessive thirst and an excess of urine constitute the main 
symptoms. From five to ten pints or even more may be passed in twenty- 
four hours. The urine looks like water and has a specific gravity from 
1001 to 1005. In some cases mosite (muscle sugar) has been found (Holt). 
Albumin and grape sugar are not found. Urea is excreted in large quan- 



1 Archives of Pediatrics. 



384 DISEASES OF THE KIDNEY AND BLADDER. 

titles, whereas uric acid is not. Restlessness by day, headache, insomnia, 
and marked irritability are the chief symptoms. Unilateral flushes of the 
face and one ear and similar vasomotor disturbances are present. There 
is an absence of perspiration. The skin is dry. Development is retarded, 
especially growth'. The appetite remains good. The temperature may be 
subnormal. 

Prognosis. — The disease has been known to last years. Some cases 
recover spontaneously. As a rule, it is wise to give a guarded prognosis. 
Cases of diabetes insipidus are very susceptible to other diseases and usually 
die from some complication. 

Treatment. — A very nutritious diet consisting of milk, meat, eggs, and 
fruit with some restriction as to the quantity of liquid should be made. 
Restoratives such as Fowler's solution, iron, and codliver-oil will sometimes 
do good. When marked nervous symptoms exist, then atropine, Dover's 
powder, belladonna and the bromides may be tried. Change of air such as 
an ocean voyage or mountain air may be of benefit. 

Diabetes Mellitus. 

The pathological studies of Weichselbaum and Opie at the Rockefeller 
Institute have established the relationship which the pancreas and more 
especially the islands of Langerhans bear to this disease. The internal 
secretions, notably the adrenal system, play an important part in influencing 
the metabolism of fat, casein, and the carbohydrates. Congenital syphilis 
is sometimes responsible for diabetes. Predisposition must also be con- 
sidered when the tendency toward family diabetes is noted. 

Saundby, in a report of 2011 cases of diabetes in adults and children, 
found only 15 occurring in children under 5 years of age, and 58 in children 
under 10 years. The extreme rarity of diabetes is recognized. 

Acidosis is generally considered to be a result of the diabetic condition. 
It is probable, however, that an acid condition may have much to do with 
the causation of diabetes. This condition has been termed "acidsemia" — 
hyperacidity or, rather, hypoalkalinity of the blood. It has no connection 
with the term "acidosis," this latter being considered as, occurring only 
when oxybutyric acid or its congeners (acetone or diacetic acid) are present. 
Aeidsemia is an extremely common, everyday occurrence and, unfortunately, 
it is all too often overlooked in routine work. A one-sided dietary in which 
meats, fish, fats, etc., predominate produces organic acids, whereas a dietary 
of cereals, milk, vegetables, and fruits tends to maintain the normal alka- 
line condition by reason of the food-salts they contain in their best and 
most assimilable form. 

According to the theory of Naunyn and his school, the diminution of 
the alkalinity of the blood and tissues is at the root of the essential nature 



COLICYSTITIS. 385 

of the diabetic intoxication. This they regard as a true acid poisoning, the 
culminating point of which is eventually diabetic coma. 

The carbohydrates form about one-half the diet of a growing child. 
The adult diet contains about one-third carbohydrates. The liver, pan- 
creas, and intestinal glands of the child assimilate much more carbohydrate 
than those of the adult. 

Symptoms. — The most prominent symptoms noticeable are irritability 
and general indisposition, increased thirst with associated polyuria. Some- 
times the extreme thirst and polyuria are wanting. Fever seldom occurs. 
Tenderness is sometimes present over the region of the pancreas. The 
knee-jerks are sometimes entirely absent during the height of the disease. 
When a tendency toward slow healing is noted in surgical conditions, then 
we should suspect glycosuria. Albumin when present is a serious factor. 
Wegeli found that in 13 cases ending fatally albumin was present. Acetone 
and diacetic acid are very frequently found in infantile glycosuria. 

The urine may vary between 1% and 10 pints in twenty-four hours. 
The specific gravity varies between 1.008 and 1.050. The quantity of 
sugar varies between 1 and 6 per cent., depending on the time of the day 
and the type of food ingested. Albumin when present is usually a serious 
complication. 

Prognosis. — The prognosis is always grave. When the urine contains 
diacetic and oxybutyric acids the condition is more serious than when the 
urine contains sugar alone. 

Eoughly stated, the duration of the disease may be about six months, 
although some children linger for years. 

Treatment. — The body demands carbohydrates; hence the treatment 
should aim to secure a tolerance for carbohydrate food. Milk, oatmeal oc- 
casionally, cabbage, lettuce, asparagus, vegetable soups of tomato or spinach, 
eggs, chicken, beef, and nuts, chiefly almonds, should form the bulk of the 
diet. Honey contains levulose and is sometimes well borne. 

A school child should be removed from school and sent to the country. 
The method of living should be entirely changed. When acidosis is present, 
10 to 15 grains of bicarbonate of soda may be given three or four times a 
day. Atropine, 1 / 200 to 1 / 100 grain three times a day, and methyl bromide, 
V120 grain, should be tried. 

COLICYSTITIS. 

We are chiefly indebted to Escherich for calling our attention to this 
condition. 

Bacteriology and Pathology. — The bacterium coli commune gives rise 
to this condition. The bacteria can migrate through the female urethra 
and set up a cystitis. When the intestinal mucous membrane is not intact, 



386 DISEASES OF THE KIDNEY AND BLADDER. 

as, for example, 1 in catarrhal enteritis, these bacteria can enter the bladder 
by migrating through the intestinal mucous membrane. 

Symptoms. — There is fever and irritability of the bladder shown by 
tenesmus. The urine contains pus, sometimes traces of albumin, and has a 
very foul odor. As a rule, the urine is milky or cloudy, or it may be dark 
in color. In some cases there may be vomiting and headache associated with 
pains in the bladder and in the back. 

Prognosis. — The prognosis is good. 

Treatment. — Internally, 3 to 5 grains of urotropin, several times a 
day, or oleum gaultheria, 1 to 3 drops, three times a day, or salol, 3- to 
5- grain doses, three times a day, may be given. 

Locally. — The bladder should be washed with a double current catheter. 
A weak permanganate of potash solution should be used, 3 or 4 ounces 
being injected at one time; this should be continued until several pints 
have been used. In some cases irrigations of a bichloride of mercury solu- 
tion, 1 to 4000, repeated several times a day, may be useful. 

Urethral Calculi (Vesical Calculi; Stone in the Bladder). 

This condition is extremely rare in infancy. It is not so rare in chil- 
dren after the third year, owing to their solid diet. Stone in the bladder 
is usually composed of uric acid, and is often the result of uric acid in- 
farction in the kidney. In this condition calculi pass from the pelvis of the 
kidney through the ureters and, lodge in the bladder. 

Symptoms. — While urinating there will be a sudden cessation of the 
now of urine. Pain either in the penis or in the perineum is sometimes 
described. As has been described (in the articles on "Cystitis"), whenever 
severe tenesmus exists, causing prolapse of the rectum without definite in- 
testinal trouble, we should suspect trouble in the bladder. Incontinence of 
urine is sometimes present. 

Diagnosis. — If the child is old enough a diagnosis can sometimes be 
made by inserting one finger into the rectum and pressing over the bladder 
in the abdomen (bimanual examination). Although this method of bi- 
manual palpation is frequently valuable, it sometimes gives negative re- 
sults. The surest method is to explore the bladder with a sound. In very 
sensitive children cocaine may be injected into the urethra before the sound 
is passed. In exceptional cases, only with the aid of an anaesthetic, can 
a positive diagnosis be made. 

Treatment. — Such cases should be treated by the surgeon, although an 
attempt at crushing the stone might be made. The radical operation of 
suprapubic lithotomy may be necessary. 

Very large calculi have been seen by me in the Stephanie Children's 
Hospital, in Buda-Pest. Professor Bokai told me that from certain districts 



CHRONIC CYSTITIS. 387 

in Hungary they receive many cases of large vesical and urethral calculi. 
It is therefore quite evident that the calculi are intimately associated with 
the geographical conditions favoring the same. 

Acute Cystitis. 

This condition is seldom seen in children. 

Etiology. — It is most usually due to the invasion of pathogenic bac- 
teria, such as the bacterium coli and the gonococcus. 

It is most frequently the result of an extension of an infection from 
the external genitals through the urethra into the bladder, so that blenor- 
rhcea in children may be an exciting cause of acute cystitis. It has also 
been known to arise from typhoid bacilli eliminated through the kidneys 
by the urine. 

Stone in the bladder and intestinal irritants, such as turpentine or 
copaiba, have been known to cause cystitis. 

Females are more prone to this affection than males. 

Symptoms. — .Very frequent desire to urinate, accompanied by pain on 
urination, is the principal symptom. The urine has a reddish color, but 
later in the disease has a light color. Its specific gravity is high. The 
reaction of the urine is alkaline. On standing there is a thick sediment 
consisting of mucus, pus, and blood. Microscopically, there are pus cor- 
puscles, squamous epithelium, and blood-corpuscles. In females it is neces- 
sary to use a catheter in drawing off the urine to obtain a specimen for 
examination, as the epithelium of the bladder and the vagina are strikingly 
similar. 

Prognosis. — This is invariably good. 

Treatment. — Bladder washing with mild antiseptic solutions, such as 
a 1 per cent, boric acid or bichloride, 1 to 5000, or a weak permanganate 
of potash solution, is useful in some cases. Alkaline waters, such as the 
White Eock, Lithia, or Appollinaris, in large quantities should be given. 

Internally the diet should be regulated so that the child receives milk 
and Seltzer, thin soups and broths, fruit and fruit juices. Meat and all 
spices must be avoided. Only bland articles may be permitted. 

Drug Treatment. — Urotropin, in doses of 5 to 10 grains, several times 
a day, is very beneficial, or Dover's powder, 1 or 2 grains, several times a 
day, will do good. In very high fever an ice-bag can be applied over the 
bladder. 

Chronic Cystitis. 

This condition is usually associated with a malignant growth in the 
bladder, such as a tumor, or frequently by stone in the bladder. It may 
also be due to a general tuberculosis with special local manifestations in 



388 DISEASES OF THE KIDNEY AND BLADDER. 

the bladder. The composition of calculus is mainly uric acid, with large 
quantities of phosphates from the alkaline urine. 

Symptoms. — From the constant dribbling of urine the child will have 
an offensive urine smell resembling ammonia about him. 

There is an irritation around the external genitals, due to excoriation 
from the moisture. If stone is the cause of this condition the urine will 
be interrupted while passing and the child will complain of pain. The 
pain is difficult to localize, although it is described as being at the end of 
the penis. Girls will localize the pain at the meatus. Prom severe tenesmus 
there may be prolapse of the rectum. 

The wine resembles the urine of an acute cystitis. Tubercle bacilli are 
found in bladder tuberculosis. 

Prognosis. — This depends upon the condition of the child and on the 
cause of this affection. A cautious prognosis is necessary in tuberculous 
affection, or if a tumor exists. 

Treatment. — If a stone is present the treatment is surgical. Urot- 
ropin and salol are very valuable, and I have seen permanent benefit from 
their use. 

Ifc Sodium sulpho-carbolate 25 grains 

Sig. : Divide into 5 powders. One powder every three hours in an alkaline 
water is also beneficial in some cases. 

Bladder washing and the diet as described in the article on "Acute 
Cystitis" should be employed in chronic cases. 

When there is a general atony of the body, then this condition will fre- 
quently result in the weakening of the sphincter vesicae muscle or in the 
spasm of the detrusor urinse muscle. Other conditions causing enuresis 
are lithiasis vesicalis, and where stones are suspected the bladder must be 
very cautiously inspected. 

Children that convalesce from a severe form of disease, such as typhoid 
fever or any long-existing febrile disorders, will usually have enuresis as a 
result of a general breaking down of the body wherein the muscles lose 
their tone. 

Other conditions causing irritation may be enumerated as congenital 
phimosis or adhesions of the prepuce, strictures of the urethra; also irrita- 
tions from worms, such as ascarides, commonly known as pin-worms; fis- 
sures of the anus; frequently also in older children masturbation and 
vulvitis may be considered as possible causes of this condition. (Bead 
article on "Lithuria") 

Calcareous deposits in the kidney or stone in the bladder, the over- 
loading of the urine with lithates or phosphates, have frequently caused 
abnormal irritations resulting in enuresis. 



ENURESIS. 389 



Enuresis. 



An involuntary emptying of the bladder during the day is known as 
enuresis diurna. When this condition exists at night it is known as enu- 
resis nocturna. 

Causes. — (a) Organic; (&) functional. 

Organic Causes. — Any inflammatory condition involving the urethra 
or bladder, or diseases of the brain or spinal cord, frequently cause this 
condition. 

Thiemich 1 considers this condition, when occurring in a child who 
has been clean for months or years, and who shows no sign of organic dis- 
ease of the urogenital or nervous system, as a sign of that general neurosis, 
hysteria. In children hysteria usually occurs in a monosymptomatic form. 
The children who suffer from enuresis at some period usually come of a 
neuropathic family, and later show some other symptoms of hysteria. 

Functional Causes: Adenoids. — It is not infrequent to find that ob- 
structions of the nose and in the nasopharyngeal spaces can cause enuresis. 
One of the most frequent causes met with is adenoids. It is a safe rule to 
examine the pharyngeal vault when enuresis exists. My experience has 
been that over 50 per cent, of the cases of enuresis seen in my clinic have 
adenoid vegetations. 

Tight Prepuce. — If other irritations, such as a tight prepuce, exist, 
then circumcision must be insisted upon. If irritation exists in the urine 
on account of an excess of lithates or phosphates, then internal treatment 
must be directed toward relieving this condition. (Eead article on "Lith- 
aemia") 

Prognosis.— The prognosis of this condition is usually good. In ob- 
stinate cases it may be valuable to insist on a change of air ; thus, removing 
the patient from the city to the country or to the seashore is of value in 
some severe cases. 

Treatment. — A very bland, non-irritating diet, consisting of cereals 
and milk, will be indicated. All spices, alcoholics, coffee, and tea must be 
prohibited. Do not permit liquids to be taken before retiring. It is also 
important to have the bladder emptied immediately before retiring. 

Drug Treatment. — One of the best drugs is strychnine in doses of 
Vioo grain, three times a day, gradually increased. In addition thereto 
small doses, 1 / 10 grain, gradually increased, of the extract of belladonna. 
When a general atony exists, then nothing will be better than iron given in 
the form of elixir of quinine, iron, and strychnine. Massage and gentle 
friction of the whole body, cold sponging, especially of the spine, are valu- 
able adjuvants to the treatment of this condition. A cold douche di- 



1 Berl. klin. Woch., vol. xxxviii, No. 31. 



390 DISEASES OF THE KIDNEY AND BLADDER. 

rected to the spine, especially to the lumbar region, will be found of great 
assistance. 

Fowler's solution and iron are very valuable in weak children. 

For incontinence of urine, internally may be given : — 

Ifc Ext. rhus aromaticse, fl 10 minims 

Syrupi aromatici 20 minims 

Aq. destillatse q. s. ad 1 drachm 

Sig.: This amount to be given three times a day. 

Or:— 

3$ Liq. atropinse sulphatis 1 ^ drachms 

Liq. strychninse hydrochloratis 45 minims 

Syr. aurant q. s. ad 1 ounce 

Sig.: For a child 14 years old, 5 drops at night; increase gradually. Younger 
children in proportion. 

The Use of Electricity. — Faradic electricity applied over the bladder, 
and also over the lumbar region of the spine for several minutes every day, 
and gradually decreased to every two or three days, is of value in some 
cases. 

According to Thiemich, excellent results are obtained by means of pain- 
ful faradization, not necessarily of the sphincter vesicae, but of the arms, 
back, or thighs. Care should be taken to prevent the impression that the 
treatment is a punishment, but instead it should be explained that the 
measure is certain of success, even though painful. More than one appli- 
cation is rarely required if care and tact be exercised. As in all forms of 
hysteria, isolation and removal from home are the most potent of all 
remedies. 

Mechanical Treatment— The passage of cold sounds and the dilatation 
of the urethra by this means are sometimes very effectual. Elevating the 
foot of the bed is of value in some cases. The child should not be allowed to 
sleep on its back. To prevent this position it is advisable, to tie a towel 
around the child's body so that the knot is in the center of the back. This 
will awaken the child if it turns on its back and will compel it to sleep on 
the side. 



PART VI. 

DISEASES OF THE RESPIRATORY SYSTEM. 



CHAPTER I. 
DISEASES OF THE NOSE AND THROAT. 

Acute Nasal Catarrh (Rhinitis; Coryza). 

Infants sneeze normally during the first few days of life, the me- 
chanical irritation of dust in the air being the cause of the same. The 
great difference between the intrauterine temperature and the temperature 
of the air renders the new-born baby sensitive and invites respiratory 
catarrh. 

Etiology. — The micrococcus catarrhalis is usually found to be the 
cause of this condition. Weakened and delicate infants are more susceptible 
to the development of nasal catarrh. For this reason infants with hereditary 
disease, such as syphilis, have constant catarrh. 

The handkerchief containing dried secretions laden with bacteria fre- 
quently disseminates this disease. Children who are too warmly clad and 
muffled are rendered more sensitive; they are susceptible and usually suffer 
with rhinitis. Recurring catarrh usually indicates the presence of adenoids. 
The vault of the pharynx should be explored with the finger for a positive 
diagnosis. 

Diagnosis. — Acute nasal catarrh must not be confounded with syph- 
ilitic rhinitis. The history should be carefully noted. Rhinitis is one of 
the earliest symptoms of measles ; hence the buccal mucous membrane should 
always be examined for the presence of an enanthem. 

If the temperature is high — 102° to 103° F. — and there is an eruption, 
then the possibility of measles should not be overlooked. In all cases of 
measles the pharynx and tonsils should be carefully examined. Diphtheria 
of the pharynx frequently has an acute rhinitis associated with it. Per- 
tussis is very often preceded by rhinitis. Inflammation of the lachrymal 
duct is at times associated, causing acute conjunctivitis. Sometimes the 
inflammation will extend through the Eustachian tube and cause otitis. 
In older children deafness is frequently caused by closure of the Eu- 
stachian tubes. 

Treatment. — Hygienic Treatment: Put the child to bed if there is 
fever, but if the temperature is normal then keep the child indoors in a 

(391) 



392 DISEASES OF THE NOSE AND THROAT. 

room with a temperature of 70° F. The body should be warmly clad after 
having been given a good tub bath, followed by friction with a coarse 
Turkish towel. 

Rhinitis tablets, containing the following ingredients, for the'prophy- 
lactic and general treatment of catarrh of the nose and throat, have been 
used by me: — 

I£ Soda salicylate 1 grain 

Tinct. aconite 1 minim 

Tinct. belladonna Vio minim 

The above quantity is for one tablet. 

One tablet can be given with water every three or four hours to a child 2 
years old; smaller children in proportion. 



Fig. 115. — Atomizer. 

Medicinal Treatment. — The gastro-intestinal tract requires cleansing. 
A drachm of castor-oil at the commencement of treatment is beneficial. 
The best drugs are quinine and belladonna given internally. The quinine 
chocolates, 1 grain of quinine, can be given to a child 1 year old; to an 
infant six months old one-half the dose. Fluid extract of belladonna, 1 / 16 
to % niinim, three times a day. Salol tablets, containing 1 grain of salol, 
can be given with benefit every three or four hours. 

Local Treatment. — A solution of adrenalin chloride, 1 to 10,000, may 
be used to cleanse the nostrils in very young infants. In older children a 
solution of 1 to 4000 may be used for the same purpose. 

The discharge can also be removed by irrigating with a 1 per cent, 
boracic acid or borax solution or a 1 per cent, table salt solution, contain- 
ing some glycerine, with an atomizer (see Fig. 115) or with Lefferts's poste- 
rior and anterior nasal syringe, followed by an alboline spray. The fol- 
lowing prescription is useful for the nasal toilet: — 

Ifc Table salt 1 drachm 

Borax 1 drachm 

Water 8 ounces 



ACUTE NASAL CATARRH. 393 

Aspirin or novaspirin in 1- to 3- grain doses every three hours, depend- 
ing on the age of the child, is indicated. Locally, the inunction of the 
following ointment in the nostrils will lessen the thickened nasal secretion. 

$ Pulv. camphor 5 grains 

Pulv. acid boric 10 grains 

Menthol 1 grain 

Vaseline 1 ounce 

Other valuable preparations for cleansing the naso-pharyngeal spaces 
are DobelPs solution, borolyptol, and glycothymoline. 

Dobell's Solution. 

I£ Sodium biborate 1 drachm 

Sodium bicarb. . 1 drachm 

Glyc. of carb. acid 2 drachms 

Water to make V2 pint 




Fig. 116. — Lefferts's Posterior and Anterior Nasal Syringe. 

Borolyptol contains 5 per cent, acetoboroglyceride ; 0.2 per cent, for- 
maldehyde, in combination with the active antiseptic constituents of pinus 
pumilio, eucalyptus, myrrh, storax, and benzoin. 

This is a very bland, mildly astringent solution adapted for the naso- 
pharynx. I frequently use this solution as a menstruum for carbolic acid 
or bichloride. All solutions used in the nose should be non-irritant; hence 
caustics should be avoided. 

Seileb's Solution- 
is Sod. bicarb 1 ounce 

Sod. biborate 1 ounce 

Sod. benzoat 20 grains 

Sol. salicylate 20 grains 

Eucalyptol 10 grains 

Thymol 10 grains 

Menthol 5 grains 

Oil of gaultheria 6 drops 

Glycerine 8% ounces 

Alcohol 2 ounces 

Water 16 ounces 

Tablets sold in shops under the name of Seiler^s tablets can be dis- 
solved in 4 ounces of water. They are of the same strength as the solution 
here mentioned. 



394 



DISEASES OF THE NOSE AND THROAT. 



Cocaine and eucaine, which are so valuable in adults, should not be 
used in children. My preference is for novocain. In older children the 
inhalation of equal parts of tincture of iodine and aqua ammonia every 
half -hour will frequently abort the disease. 

Dietetic Treatment. — The nursing infant should be fed at regular 
intervals. If bottle-fed the same regularity should be observed. No stimu- 
lants should be given. It is unwise to give codliver-oil or other restoratives 
when radical treatment is called for. 

Nasopharyngeal Catarrh Frequently Associated with 
Gastric Catarrh. 

The association of naso-pharyngeal catarrh with catarrh of the stomach 
may at first seem peculiar. When, however, the anatomical' relationship 





Fig. 117. — Lenox Nasal Douche. 



Fig. 118. — Graduated Douche Suit- 
able for Older Children. 



of the mucous membrane of the naso-pharynx with the oesophagus and 
stomach are considered, an extension of the disease can easily be understood. 
There are certain points which have a decided bearing on the etiology of 
gastric catarrh when caused by naso-pharyngeal disease. Such are: — 

1. The fact that children rarely, infants never, expectorate. When 
they have post-nasal catarrh and there is an irritation from mucous or muco- 
purulent secretion infants invariably swallow the same. It is for this 
reason that the old-fashioned dose of ipecac or castor-oil was given, not to 
relieve the cough nor to hasten the expectoration, but rather to cleanse the 
stomach from non-expectorated secretion. 

2. Loss of Appetite. — The loss of appetite, usually associated with se- 
vere naso-pharyngeal catarrh in which the stomach has been normal up to 
the beginning of the attack, is usually due to the swallowing of large quan- 
tities of this infectious secretion. 



INFLUENZA. 395 

The benefit derived from curing a cold with a dose of castor-oil simply 
means removing some of the swallowed muco-purulent secretion from the 
stomach which should have been expectorated. 

When catarrhal disease affecting the naso-pharyngeal space is muco- 
purulent and continues for a long time in very young infants, we can easily 
see why the loss of appetite may be the means of causing deficient nutri- 
tion. Such cases may end fatally. The importance of attending to diseases 
in the naso-pharynx can be seen when it is considered that diphtheria can 
spread from the pharynx to the esophagus, and also to the stomach. 

While it is true that diphtheritic gastritis is reported very rarely, it is 
well to bear such cases in mind, for they show the great danger to the 
stomach from an infectious catarrh located at the food entrance. There 
is usually a deficiency of hydrochloric acid secretion in all severe catarrhal 
diseases. This is most apparent in those febrile conditions which accom- 
pany diphtheria. It is for this reason that it is not very difficult for 
the stomach to be the seat of an infection if diphtheritic membrane is 
swallowed. 

It is of the greatest importance to have every child's throat in a nor- 
mal condition. Adenoid vegetations and diseased tonsils favor the devel- 
opment of malignant disease. The vast majority of patients who are 
infected with diphtheria owe this infection to the diseased state of their 
throat, which favors the development of pathogenic bacteria. This can 
as easily be verified in children as in adults. It is rare to find a case of diph- 
theria in which a previous normal throat existed. Hence it would seem, 
plausible to eradicate all trifling as well as serious nose and throat disease, 
and aim to secure a healthy state if we are to ward off infections. 

Influenza. 

Influenza is a communicable and a very infectious disease spreading 
with great rapidity from person to person. 

Bacteriology. — There is no distinct micro-organism or specific agent 
known to date, which is found in all cases of influenza. Most investigators 
agree that smears taken from the nose and throat vary in their findings. 
Kinsella arrives at the same conclusions as MacCallum in studvino- the 
pathology of pneumonia. Both state the causative agent is unknown, and 
that the agent produces a lowering of resistance to bacterial invasion, hence, 
is followed frequently by pneumonia caused by the different t}-pes of pneu- 
mococcus, streptococcus aureus, streptococcus hemolyticus, or the influenza 
bacillus of Pfeiffer. Goodpasture studied a series of broncho-pneumonias 
following influenza in which the hemolytic streptococcus was frequently 
found. 

Influenza occurs in the most sanitary and best ventilated houses equally 
as severe as in the most thickly congested dwellings of the city, or in the 
country. It is disseminated bv convalescents — those who have recentlv re- 



396 DISEASES OF THE NOSE AND THROAT. 

covered and still have the virus or poison capable of reproducing the disease. 
The catarrhal discharges from the nose, throat, eyes and ears are believed 
to be factors in the spreading of the disease. Isolate all cases, and during 
an epidemic quarantine at least two weeks. 

Symptoms and Diagnosis. The Blood. — In influenza the white cell 
count shows a leucopenia. In some cases the leucocytes were as low as 4000. 

There is also a great similarity of the white cell count, in the blood 
findings of typhoid fever, and in many instances in which there is prostra- 
tion, a brown dry tongue, and loose alvine discharges ; one is impressed with 
the similarity of the clinical manifestations. 




Fig. 119. — Influenza bacilli. Sputum smear. (Lenhartz-Brooks.) 

The Sputum. — In a typical case of influenza which ended fatally the 
examination of the sputum showed chiefly frothy, blood-tinged serum and 
mucus with relatively little pus. Staining showed numerous pyogenic cocci 
including some in chains, believed to be streptococci ; also a moderate num- 
ber of small Gram negative bacilli, similar to influenza organisms. 

The Urine. — The urine in most cases showed traces of acetone, and 
diacetic acid with a faint trace of albumin, no pus cells nor casts. As a 
rule the urine was scanty and high colored with a depressed excretion of 
chlorides. A diagnosis of acidosis was frequently justifiable by the odor of 
the breath, the intense thirst, and the acetonuria. 

Type. — There are three distinct types of this disease encountered ; first, 
the pulmonary type which was met with in nearly 60 per cent, of the cases; 
second, the gastro-enteric type in 30 per cent, of the cases; and third, the 
meningeal type or the form in which the brain and central nervous system 
was affected in about 10 per cent, of the cases. 

Pulmonary Type. — The first symptoms noted are general prostration, 
cough and fever. The temperature usually ranges between 101° and 103°. 
The pulse-rate is accelerated and ranges between 120 and 150. The respira- 
tion varies between 30 and 50. Sneezing and rhinitis are present in many 



INFLUENZA. 397 

cases though not in all. 'The blood-vessels of the eyes and eyelids are in- 
tensely congested and injected. The eyes are dull and frequently sunken. 
There is a general apathetic appearance. In very young children there is 
moaning and a short hacking cough. Older children complain of intense 
muscular pain and lancinating pains in the back, arms, legs and head. The 
throat is congested, the tonsils swollen and dry. The tongue is coated and 
resembles a typhoidal tongue. The salivary glands do not seem to function- 
ate. The physical examination of the chest shows one or more small areas 
of infiltration and patches of consolidation resembling the usual form of 
bronchopneumonia. In some cases moist rales as well as sonorous rales can 
be heard on auscultation of the chest. When an area of consolidation is 
present crepitant rales will be heard at the end of inspiration. On percus- 
sion marked dullness will be heard, and distinct resistance will be noted. 

E. H., 16 years old, was infected by another member of the family. The first 
symptoms noted were a slight temperature of 101°, and respiration 28. The sub- 
jective symptoms were slight malaise and slight headache, but no constitutional 
disturbance. The diagnosis of mild influenza was made. Eliniinative treatment 
with a restricted diet was ordered. The following day a slight improvement was 
noted. I did not see the girl on the third day. On the fourth day I was called and 
found the temperature rising, more systemic disturbance, prostration, evidence of 
toxicity, slight headache, muscular pains, respiration 36, pulse 128. Rhonchi were 
found scattered on both sides of the chest, but no evidence of consolidation. The 
temperature rose to 105°, and it was impossible to lower it with antipyretics and 
sponging. A central pneumonia was diagnosed. The inflammation spread from 
lobe to lobe. When seen in consultation with Dr. Walter B. James the diagnosis of 
influenzal pneumonia with marked toxicity was confirmed. Prognosis bad. On the 
following day there was an extension of the pneumonia, toxicity still marked, pulse 
full, bounding, and with high tension, and very irregular. There was marked 
cyanosis of the lips, face, and finger nails. The expectoration was of the usual 
rusty character and the specimen submitted to Dr. Frederic Sondern was reported 
upon as follows: "The specimen consists chiefly of frothy blood- tinged serum and 
mucus with relatively little pus. Staining shows numerous pyogenic cocci including 
some in chains, believed to be streptococci; also a moderate number of small Gram- 
negative bacilli, morphologically similar to influenza organisms. Tubercle bacilli 
are not present." 

The blood count showed a marked diminution of the white cells and a low 
poly nuclear percentage. The blood did not show the clinical picture of a leucocy- 
tosis in pneumonia. Small lymphocytes, 24 per cent.; large mononuclear cells, 2 
per cent.; polymorphonuclear neutrophiles, 56 per cent.; hemoglobin, 86 per cent. 

Infantile Pulmonary Type. — In a family suffering with influenza the two-year- 
old infant refused its food, showed excessive thirst, and was restless. When seen 
by me there was eoryza, cough, a decided acetone odor to the breath, and prostration. 
The temperature ranged between 102° and 103°. Owing to the family infection the 
diagnosis of influenza was made. The lungs showed a few rales on both sides, in- 
creased respiration, but no distinct evidence of consolidation. On the following day 
the temperature rose to 105°. The increased respiration, the toxic condition, the 
labored breathing, dyspnoea, and cyanosis all pointed to a central pneumonia. On 
the third day of illness • distinct bronchial breathing was made out, as were also 
crepitant rales at the end of inspiration. There was a corresponding increase of 
temperature, pulse and respiration; and marked rigidity of the muscles of the 



398 DISEASES OF THE NOSE AND THROAT. 

extremities* and neck. The eyes were fixed and the ' child appeared to be in a 
state of spasmodic rigidity. There was constant moaning and crying on the slightest 
touch. This hyperesthesia lasted about four days. On the seventh day of illness 
there was a sudden drop in the temperature from 105° to 96.4°. The meningeal 
symptoms gradually subsided and the child made a complete recovery. 

Ten cubic centimeters of Squibb's leucoeytic extract was injected on the third 
day of illness. This appeared to stimulate the white cells, for a decided increase in 
the leucocytes was evident during the following twenty-four, thirty-six, and forty- 
eight hours respectively. 

Meningeal Type. — In this severe form occasionally seen the toxin se- 
lects the brain and central nervous system, and there are symptoms of men- 
ingismus and meningitoid manifestations. The diagnosis depends on the 
findings in the spinal fluid obtained by lumbar puncture. The meningeal 
symptoms resemble those seen in the diplococcus form of meningitis but are 
easily differentiated therefrom. The following case shows the intensity of 
the infection, but one in which recovery took place. A guarded prognosis 
was given. 

M. G., eleven years old, was seen in consultation with Dr. J. Tannenbaum. 
She had had a mild form of influenza lasting four days, with symptoms of disordered 
stomach and cough. Three days before my seeing the child- she suddenly collapsed 
and was in a stupor with temperature of 104°. She was pulseless when seen by Dr. 
A. L. Goldwater. There was no distinct evidence of meningitis. She recovered with 
restoratives, and on the following day had a marked delirium. Two days later she 
was in a distinct coma lasting several hours. When seen by me she was appar- 
ently bright in the morning, and in a distinct stupor at the time of examination. 
There was marked rigidity of the muscles, the pupils responded sluggishly, the 
patellar and plantar reflexes were absent, there was marked hyperesthesia of the 
skin, and a tache cerebrale was present. The symptoms so resembled those of a 
tuberculous meningitis that a tuberculin test was made, also a lumbar puncture. 
The von Pirquet test was negative. About 15 cubic centimeters spinal fluid was 
aspirated. The fluid was examined by Dr. Frederic Stondern who reported a normal 
fluid — no tubercle or other micro-organism present. The diagnosis of toxic influenza 
was made. The collapse previously reported was attributed to a toxic myocarditis. 
There was no nephritis present. The severe toxicity suggested a fatal outcome. The 
child made a complete recovery. 

Gastric Type. — A sudden onset characterized by vomiting and loose 
bowels, similar to an acute milk infection or a colitis as met with in mid- 
summer, was frequently seen. Fever ranging between 101° and 104°, with 
catarrhal stools containing mucus— at times tinged with blood, with tenes- 
mus and rapid emaciation, occurred frequently. -Milk was not retained. 
There seemed to be an intolerance to fat, therefore, milk skimmed of all 
cream, or boiled and strained buttermilk was given. In a few cases dry 
milk was given with excellent result. 

The following case is interesting because it was an unusually severe type 
of gastro-enteric infection lasting about nine days, and ending in recovery. 

Leonard F., 10 months old, had been thriving, digesting normally, and seemed 
to be in good health. Suddenly he began sneezing, vomiting, had loose bowels, and 



INFLUENZA. 



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40 DISEASES OF THE NOSE AND THROAT. 

cried as though in pain. His temperature was 101°, pulse 124, and respiration 30. 
Diluted milk was ordered, and a dose of castor oil was given, but the temperature 
continued to rise to 103°, pulse 140, respiration 38. This was on the second day of 
illness. On the third day the temperature rose to 105°, pulse 150, and respiration 
60. A slight cough developed. Vomiting persisted after each feeding. No medica- 
tion was retained. There was distinct evidence of consolidation. Barley water was 
ordered. Cold packs, later cold tubbings were ordered to reduce the temperature. 
The infant seemed in intense pain, moaning or crying almost continuously, especially 
on being handled. He shrieked with pain when an arm or leg was moved. The 
head and neck were slightly rigid. The reflexes were exaggerated. On the fifth day 
the temperature which had remained at 105°, gradually came down by lysis, drop- 
ping one degree each day. The vomiting and loose bowels continued for more than 
one week. The only milk retained was dry milk (Honor brand) of which two 
tablespoonfuls to six ounces of hot water were given every four hours. The interest- 
ing feature of this case was the sudden onset of vomiting and looseness of bowels 
which lasted eight days in all and ceased suddenly. 

Complications. — Otitis frequently is followed by mastoiditis and pneu- 
monia by empyema. Suppurative meningitis was seen in two cases. 
Nephritis is fatal unless detected early. Suppression of urine is a danger 
signal. Pericarditis and endocarditis frequently follow influenza. 

Prognosis. — If a child has been ill three or four days with a high fever 
and the kidneys show marked toxic nephritis, or the heart sounds are irregu- 
lar, then a cautious prognosis should be given. Sinus arhythmia is a symp- 
tom frequently noted and one showing cardiac muscular insufficiency. In 
such cases a guarded prognosis is -necessary. 

Persistent vomiting and associated malnutrition are serious factors to 
be considered before an opinion is given. When active treatment has been 
instituted early in the disease, and the kidneys, skin, and bowels eliminate 
the toxin, then a far better prognosis can be given than when the case has 
received no treatment during the first three days. 

Treatment. — Best results were obtained with the alkaline treatment. 
Five- to 15- grain doses of citrate of soda, bicarbonate of soda, or bicar- 
bonate of potassium may be given, with water, every hour. When the 
stomach would not retain food nor medication, then six to twelve hours' 
rest was ordered, and a colonic injection of 1 drachm of soda bicarbonate to 
4 ounces of hot water (temperature 110° to 115°) was given every three 
hours. When toxic symptoms existed then an intravenous injection of a 
10 per cent, sterile sodium bicarbonate solution was given in the median 
basilic or jugular vein. If the infant was under two years of age, and the 
fontanel still open, the longitudinal sinus was the vein of choice for rapid 
systemic medication. 

To relieve intense neuritis pyramidon in 3-grain doses was given every 
three hours. Urotropin in 2- to 5- grain doses several times a day, was 
ordered when nephritic symptoms existed. To reduce fever give a luke- 
warm tub bath, followed by a warm pack and blanketing until profuse per- 



INFLUENZA. 



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402 DISEASES OF THE NOSE AND THROAT. 

spiration results. This eliminates toxin and reduces fever without depres- 
sing the heart. 

Food. — Fermented milk such as buttermilk, or milk fermented with 
the Bulgarian bacillus is refreshing and antitoxic. Weak tea containing 
the white of a raw egg with a pinch of salt, lamb broth or chicken broth 
may be given in three- to four- hour intervals. No solid food should be 
permitted. Orange juice, pineapple juice or apple sauce may be given to 
quench thirst. When the fever subsides semi-solids may be given. 

Vaccine Prophylaxis and Serum Treatment. — My own experience in 
prophylactic serum injections 1 has shown me that we cannot .guarantee im- 
munity by the use of vaccines. In some cases following the vaccine injec- 
tions no infection took place, in other cases the disease did appear, but in a 
mild form. 

The vaccine does no harm and may modify the intensity of the in- 
fection. Do not pin too much faith on the efficacy of these serums and 
vaccines but use all remedies to eliminate the infection even though serum 
or vaccine is used. 

Specific results are being reported from the use of bacterial protein 
injections. The vaccine consists of a saline suspension of heat-killed 
organisms each containing 100 million influenza bacilli, 100 million pneu- 
mococci, Types I, II, and III; 100 million streptococci and 100 million 
staphylococci 

Edward Gr. Cary and Dudley Roberts, IT. S. Army, report excellent 
results from the use of influenza vaccine during the recent epidemic. 2 
These patients were adults, and being hospital cases under excellent super- 
vision, the results are convincing. 

To be effectual the vaccine must be injected intravenously and not hy- 
podermically. The dosage consists of 0.2 c.c. doubled daily until four doses 
have been given. Following the injection there is a sharp reaction consist- 
ing of a chill and a rise in temperature of 1 to 3 degrees. When this re- 
action occurs it proves that the body is responding. If there is no reaction 
then the vaccine is ineffectual. 

Foreign Bodies in" the Nose. 

Children frequently while playing with beans, beads, shot, etc., stick 
them in the nose. If allowed to remain they frequently become encrusted 
with carbonate and phosphate of lime. Then it is known as a rhinolith. 
An angular forceps or a polypus forceps has frequently dislodged these 



1 My experience was gained with the influenza serum of the New York Board 
of Health, likewise with the serum sent me by Dr. Rosenow of the Mayo Foundation. 

2 Journal of the American Medical Association, March 29, 1919. 



TONSILLITIS. 403 

foreio-n bodies. A nasal irrigation into the unobstructed nostril will some- 
times assist in removing the foreign body. 

Tonsillitis (Angina Catarrhalis). 

This is an acute inflammatory lesion, undoubtedly due to the infection 
of the structures of the tonsil by micro-organisms which enter the lacunae 
or lymph channels. 

Bacteriology and Pathology. — The tonsils 1 are lymphoid structures 
closely resembling Peyers patches of the small intestine. Various species 
of cocci and bacilli are to be found within the lacunae, within the closed 
follicles, and even within the epithelial cells of tonsils removed during the 
acute stage. 

' ;■•■ * ';* .-jVy/rv. ,•/ 






Fig. 122. — Angina Tonsillaris. Methylene-blue Staining. Zeiss Immersion 1-12, 
Ocular 4. (After Jager, Klin. Microscopy.) 

Leucocytes in large numbers are found associated with the microbes. 

During the presence of inflammatory conditions, such as the presence 
of the contagium of diphtheria, desquamation of the epithelial covering 
takes place. This proliferation of the cells seen in diphtheria may entirely 
denude the tonsils of its epithelial covering in places. This will then per- 
mit any specific virus to be brought into contact with the lymphatics and 
then be carried into the general circulation. "We see an acute inflammation 
of the tonsils in scarlet fever, in measles, and in diphtheria. It may also 
be seen in other infectious diseases, so also in acute inflammatory mani- 
festations. 

Symptoms. — One of the most frequent diseases of infancy and child- 
hood is tonsillitis. When we are told that an infant has had a slight fever 



1 Hodenpyl in the American Journal of Medical Science, March 1, 1891, 



404 DISEASES OF THE NOSE AND THROAT. 

that passed off very quickly and has been attributed to "teething/' tonsil- 
litis among other diseases should be suspected. 

The onset is sudden. Fever is high. The temperature reaches 102° 
and may rise to 105° F. Vomiting frequently occurs. On the tonsils we 
find intense redness, and the lacunas are covered with whitish or yellowish- 
white spots, which rarely coalesce but appear as yellowish dots. 

Treatment. — Immediate relief to an inflamed tonsil can be given by a 
spray of 1 to 10,000 adrenalin chloride. Externally a hot flaxseed poultice, 
or in some cases with fever an ice collar, will render good service. 

Internally 1-drop doses of tincture of aconite, repeated every hour for 
five or six doses, will reduce fever, promote diaphoresis, and frequently abort 
the condition. A dose of calomel, y 2 grain, repeated every two or three 
hours until liquid stools are produced, is valuable. A steam atomizer con- 
taining a spray of beechwood creosote or pine-needle oil, to be used every 
two or three hours, loosens viscid secretions. 

Food. — As there usually is pain on swallowing solid food, it is better 
to give small quantities of liquid food. Ice-cold chicken or calfsfoot jelly, 
ice cream, raw scraped pulp of meat, the yolk of raw eggs well beaten with 
sugar, buttermilk or zoolak, is nutritious and grateful to an inflamed throat. 

The Significance of Tonsillitis in Children. 

A diagnosis of tonsillitis or quinsy is usually thought to imply that we 
are dealing with a benign, easy-going condition. That the reverse is true 
is very apparent when a critical inquiry will follow the termination of each 
and every case. In a series of 12 cases of follicular tonsillitis taken at 
random as I saw them, the bacteriological diagnosis in 7 of these cases was 
diphtheria. 

The frequency with which endocarditis and nephritis are seen implies 
that there may have been some antecedent disease from which pathogenic 
bacteria caused the valvular heart lesion, or possibly a nephritis. 

Follicular Tonsillitis, or Follicular Catarrh. 

Follicular catarrh is the most frequent form of inflammation of the 
tonsils. 

Bacteriology. — The examination of the purulent plugs of follicular 
angina reveals : — 

(a) Staphylococcus. 

(b) Streptococcus. 

(c) Pneumococcus. 



ULCEROMEMBRANOUS TONSILLITIS. 405 

Staphylococcus angina is a relatively harmless inflammatory lesion 
passing off without complications. 

The streptococcus variety is a severer type of disease associated with 
fever and glandular enlargement. This disease is associated frequently with 
a general toxaemia and may be followed by nephritis or septicaemia. 

The pneumococcus form is usually ushered in with a chill and some- 
times runs a course similar to that of pneumonia. There is usually a red- 
ness and swelling of the tonsils, lacunar catarrh, and increased secretion, 
which agglutinates and shows itself at the follicular openings as yellowish- 
white spots. 

The lymphatic glands at the angle of the jaw are sometimes enlarged 
and tender on palpation. 

Croupous Tonsillitis. 

This is a severer form of inflammation than the one above described. 
It involves the whole structure of the tonsil and most especially the crypts. 
The large quantity of fibrin which is poured out forms a distinct pseudo- 
membrane. It is very difficult to differentiate this from diphtheria. A 
culture should be taken in all cases (see the "Diagnosis of Diphtheria"). 

We cannot differentiate this disease from true diphtheria clinically 
except by resorting to bacteriological cultures. 



l~lcero-me:\ibraxous Toxsillitis. 

This disease was first described by Vincent 1 who maintained that it 
was caused by a fusiform bacillus, although a spirillum was found asso- 
ciated with it. 

Microscopically, there is a spindle-shaped bacillus along with spirilli. 
The bacillus does not stain with Gram. A clear culture is hard to obtain. 

The pseudo-membranes, whitish or grayish in color, are easily detach- 
able until the third clay, when the ulcer forms. This ulcer corresponds 
to the portion of the tonsil occupied by the pseudo-membrane. Around its 
edges the mucous membrane is reddened. The accompanying symptoms are 
difficulty in swallowing, fever, anorexia, headache, and swelling of the 
submaxillary glands. The pseudo-membrane does not increase when this 
piece of membrane is detached. The ulcer heals. 

It resembles croupous tonsillitis in its general appearance. It is often 
unilateral. The yellowish exudation seen on the tonsil greatly resembles 
diphtheria. It is a superficial necrosis, and when this tissue is wiped 
away with a swab bleeding occurs. 

There are swollen lymph nodes at the angle of the jaw. 



Arch. International de Laryngologie, 1898, No. 1. 



406 DISEASES OF THE NOSE AND THROAT. 

This disease is a local process and rarely has constitutional symptoms 
accompanying it. 

Prognosis. — The prognosis is excellent. 

Treatment. — Gargle with bichloride, 1 to 2000, or with a weak solution 
of permanganate. Locally, iodine, or 3 per cent, peroxide of hydrogen or 10 
per cent, nitrate of silver solution, can be repeated in twelve hours if no 
improvement is noted. By painting the ulceration with a 2 to 3 per cent, 
solution of neosalvarsan freshly made with distilled water, pains and symp- 
toms quickly disappear. 

*A b 




Fig. 123.— Vincent's Bacillus Found in Ulcerative Angina. A, Fusi- 
form bacillus having a thickened center and tapering toward both ends. 
Also spindle-shaped bacilli. B, Fusiform bacillus having spores. ( Original. ) 

Phlegmonous Tonsillitis (Quinsy: Peritonsillar Abscess). 

This form of angina is usually caused by an invasion of the staphy- 
lococcus. When the cellular tissue surrounding the tonsil is infected the 
inflammation may terminate in : — 

(a) Resolution. 

(b) Abscess. 

It is one of the rarer forms of inflammatory conditions met with in 
children. 

Symptoms. — The symptoms are similar to those of follicular tonsillitis. 
The temperature rises to 101° and 102° F. Sometimes as high as 105° F. 

The child, if old enough, will complain of pain on swallowing, and 
at times it may be impossible to open the mouth. On examining the throat 
the inflammation can be seen. There is a marked congestion and oedema 
involving the tonsils, fauces, and uvula. 

Holt reports a case of torticollis several days before the diagnosis of 
quinsy was established. 



CHRONIC HYPERTROPHIC TONSILLITIS. 



407 



Treatment. — Aconite in 1-drop doses, repeated every one or two hours 
for the first day, will frequently abort the disease. Guaiacol carbonate given 
in 1- to 5- grain doses every three or four hours, has served me very well in 
some instances. 

Local Treatment. — Local treatment consists in spraying the throat 
with a 1 to 2000 bichloride of mercury solution every two hours. 

An ice-bag over the neck will sometimes relieve inflammation. The 
external application of leeches will relieve congestion. When fluctuation 




Fig. 124. — Throat Spray. 

is felt the pus should be relieved by making a deep incision with a long, 
pointed bistoury. 

The Danger of Hemorrhage. — Laryngologists, as a rule, advise great 
caution in operating in this region owing to the large number of blood- 
vessels located there. 

After the incision is made the wound should be enlarged by inserting 




Fig. 125.— Throat Ice-bag. 

a polypus forceps or an artery clamp and separating the blades. By this 
means we can easily evacuate the pus and do not run the risk of bleeding. 
I am indebted to Dr. George F. Shrady for this valuable surgical hint. 



Cheoxic Hypertrophic Tonsillitis. 

The chronic enlargement of the tonsils is due to recurring inflammatory 
attacks. This hypertrophy comes from a proliferation of the lymphoid 
tissue and an increase in the connective tissue stroma. 

Etiology. — It is usually found in rachitic and subnormal children. 
Bad ventilation and improper hygiene are among the prime causes of this 



408 DISEASES OF THE NOSE AND THROAT. 

disease. In a series of several hundred children examined by me in one 
of my clinics for various diseases, 90 per cent, suffered with enlarged 
tonsils. All of these children lived in tenement houses, and we must asso- 
ciate the crowded, ill-ventilated apartments with the poisoned air inspired 
and its resulting throat disease. 

Predisposing causes, such as rheumatism in the parents, have been 
given by some authors as causative factors. 

Symptoms. — When we are told that an infant snores and breathes with 
its mouth open, then enlarged tonsils may be suspected as the cause. On 
the other hand an inspection of the post-nasal spaces should also be made 
to eliminate the presence of adenoids as the probable cause of the difficult 
respiration. 

Deafness can rarely be attributed to enlarged tonsils. It is more often 
caused by the closure of the Eustachian tubes due to adenoids. The nasal 
tone of voice often accompanies enlarged tonsils. 

Course. — Enlarged tonsils increase during childhood and remain per- 
manently until puberty arrives, when they usually shrink in size without 
treatment. 

The indications for the removal of chronic enlarged tonsils are : — 

1. Where there are repeated attacks of tonsillitis. 

2. Where there is inability to breathe sufficiently through the nose^ 
with snoring, during sleep. 

3. Nasal voice and deficient articulation. 

4. Deafness and attacks of earache. 

5. Tendency to pigeon-breast. 

When any or all of the above conditions exist then a guarded opinion 
should be given until we ascertain whether or no the case is complicated by 
adenoids. 

In the latter cases the removal of the tonsils will not suffice to cure the 
patient until the rhino-pharynx is treated for the removal of the adenoids. 

There are few conditions met with in children which are more satis- 
factory from a therapeutic standpoint than the operation for tonsils and 
adenoids. 

Dangers. — Desire 1 collected 20,000 tonsillotomies. In 9 cases bleeding 
took place. In none of these cases was it fatal, and in several it was not 
serious. 

Lefferts 2 lays stress on the ascending pharyngeal artery . as being one 
of the most, if not the most, prolific source of severe bleeding after ton- 
sillotomy. It is important to inquire if children suffer with haemophilia 
(bleeders) ; in such cases fatal haemorrhage will frequently occur. I have 



Sajous's Annual, 1891 ?ols. iv and v. 
Archives of Laryngology, vol. iii, p. 43. 



CHRONIC HYPERTROPHIC TONSILLITIS. 



409 



also met with a case of congenital syphilis in which a serious haemorrhage 
followed a tonsillotomy. This was evidently dne to a syphilitic degeneration 
of the blood-vessels. 

The Operation. — The bistoury is rarely or never used for this opera- 
tion. Some operators use a wire snare. In my experience the adjustment 
of a snare in an unruly child is so difficult and so much time is lost, that 




Fig. 126. — The Baginsky Tonsillotome. 

it is not practical. My preference has been for some form of tonsillotome. 
The Mackenzie type is a very good one. The Baginsky tonsillotome is one 
of the best. (See illustration Fig. 126.) It is simply a sharp-bladed guil- 
lotine and can be very easily adjusted. 




Fig. 127. — The ^Mackenzie Tonsillotome. 



Hemorrhage following the operation need not cause anxiety. When, 
however, haemorrhage follows, then adrenalin chloride solution in full 
strength (V 100 o) should be liberally used. It may be applied in the form 
of a spray or by means of a cotton pledget soaked with the solution. The 
galvano-cautery or the local application of peroxide of hydrogen is fre- 
quently useful. In older children small pieces of cracked ice or ice cream 
will control bleeding. 

The Use of an Anaesthetic. 1 — The local application of a 10 per cent, 
cocaine solution has been recommended by a great many authors. I have 



x Read chapter on "Anaesthesia in Children," page 885. 



410 DISEASES OF THE NOSE AND THROAT. 

used cocaine in children and have seen very bad constitutional effects, such 
as severe cardiac depression, nausea, and frequently vomiting, following its 
use. I prefer 4 per cent, novocaine solution. 

Spraying the tonsils with ethyl chloride for several seconds produces 
local anaesthesia. It is very valuable with sensitive children. In some 
instances a few whiffs of chloroform are necessary to have the child com- 
pletely under control. 

Chloroform is very rapid, but it must be cautiously given. 

It is advisable to operate before feeding, so that in the event of vom- 
iting food should not be expelled. 

It is advisable to thoroughly swab the mouth, pharynx, and tonsils 
with an antiseptic solution before the operation. For this purpose use : — 

Table salt . . . : 1 drachm 

Sterile water 5 ounces 

Or Dobell's solution. 

Apply with a cotton swab.^ 

Normally pathogenic bacteria abound in the mouth and post-nasal 
spaces. After a tonsillotomy a white croupous deposit resembling diph- 
theria will be seen. This should not be considered a diphtheritic infection 
unless the Klebs-Loeffler bacillus can be demonstrated. 

Owing to the raw surfaces following a tonsillotomy the greatest care 
must be used to isolate the patient from infectious diseases. Scarlet fever 
and diphtheria will gain access much easier soon after this operation is 
performed. 

Tuberculosis of the Tonsils. 

Schlesinger states (Forts, der Med. Pediatrics) that "up to the present 
time the parallelism between advanced tuberculosis of the lungs and tuber- 
culosis of the tonsils, as also that between mild or passed tuberculous 
processes of the lungs, with the escape of the tonsils, has only been demon- 
strated in the case of adults, but has not been observed in children. He was 
able to confirm this parallelism also in children, having found 12 cases of 
tuberculosis of the tonsils in 13 of florid tuberculosis of the lungs. The 
diagnosis of tonsillar tuberculosis is hardly possible microscopically, for the 
reason that tubercular ulcerations are only found very rarely on their 
surface; neither were the tonsils hypertrophied without exception, but 
were found pale and firm in nearly two-thirds of the cases. In 9 cases 
examined for the purpose, the tonsils were found to be affected bilaterally, 
although not with equal intensity. As to the relation between tuberculosis 
of the lymphatic glands of the neck and that of- the tonsils, in 9 cases the 
author found that the tonsils were healthy in 2. He inclines, therefore, to 
the view that a primary tonsillar tuberculosis is not to be taken for granted 
in all cases ; but we must take into account the possibility of their infection 



ADENOID VEGETATIONS. 411 

by cheesy cervical glands, by means of the return flow of lymph. The 
author finds some support for this view from the fact that in these cases 
the recent tubercles are situated at the base of the tonsils away from the 
crypts." 

L. Kingsford 1 examined the tonsils removed post-mortem from 17 
children, varying in age from 4 months to 9 years. All showed cervical 
glandular enlargement, and in 11 it was obviously tuberculous. Of the 
17, tonsillar deposits were found in 7, but only 3 exhibited any naked-eye 
tuberculous changes. Of these 3, 1 showed ulceration, a second scarring, and 
a third a sebaceous focus. Practically all the 17 were cases of secondary 
infection from either blood or sputum. The parts of the tonsils which 
were the seats of the lesions were usually the lymphoid follicles not far 
from the epithelial surface, but it is not possible to trace bacilli in from 
the crypts or surface of the organs. The author believes iti possible that 
infection may work through healthy tonsils to the cervical glands, the 
former becoming infected at a later period. 

Tuberculous tonsillitis is a very rare affection. The tonsils are rarely 
if ever the site of primary inoculation in pulmonary tuberculosis. 



Adenoids, Adenoid Vegetations. 2 

Adenoid vegetations consist of a hypertrophy of the adenoid tissue 
which exists normally in the naso-pharynx. 

Pathology. — In a less severe form the growth may be confined to the 
roof of the naso-pharyngeal cavity. In severe forms the vegetations are 
very numerous, irregular in shape, and extend from the roof of the cavity 
to the lateral walls. They grow from the fossa of Kosenmuller. They 
frequently cover the orifices of the Eustachian tubes. They are frequently, 
according to Hall, between the enlarged pharyngeal and faucial tonsils, and 
sometimes the adenoid tissue at the base of the tongue, the so-called lingual 
tonsil. 

Age. — The new-born infant as well as the premature infant frequently 
has adenoids, therefore heredity must in a measure play an important part 
in the etiology of adenoids. As a rule children reaching the fourth or fifth 
year without adenoids developing, rarely acquire them later in life. 

Symptoms. — The "adenoid habitus," the pinched expression of the 
nose and the long drawn face, are very typical. There is frequently lateral 
narrowing of the alveolar arch and prominence of the upper incisor teeth. 
Owing to the interference of respiration the mouth is kept open. The lips 
are swollen and thick. 



1 The Lancet, January 9, 1904. 

a For "Congenital Adenoids," see clinical history on page 59. 



412 



DISEASES OF THE NOSE AND THROAT. 



Spieer has directed attention 1 to the distention of the transverse nasal 
veins as one of the indications of the presence of adenoids. 

Deafness. — Deafness is frequently cansed by the presence of adenoids. 
The amount of interference caused by the adenoids will depend on the 
relation of the Eustachian tube orifice to the vault of the pharynx. If the 
orifice be situated high.' up, a small amount of growth will occlude it and 
cause auditory trouble. When the orifice is situated low down there may 
be extensive vegetations without the Eustachian tube being implicated. 2 
The voice has a muffled 
sound with a nasal twang. 
The letters m, n, and ng 
cannot be pronounced. 
Stuttering or stammering 
can frequently be cured if 
vegetations are removed ; 
the explanation being that 
the spasmodic actions of the 
muscles of the throat are 
due to reflex irritation. 
Earache frequently accom- 
panies adenoids. 

Bed wetting is usually as- 
sociated with adenoids. 
Among several hundred 
children examined in the 
children's service of a large 
dispensary, it was rare to 
find a case of enuresis that 
was not associated with 
adenoid vegetation. 

Diagnosis. — The mouth breathing, the snoring at night, the adenoid 
face, are in themselves sufficient to establish a diagnosis. To examine the 
rhino- pliar ynx for the presence of adenoids, have the nurse seated with the 
child on her lap, firmly pinning the child's feet between her knees. While 
the right hand confines the child's arms, the left hand is used to support 
the head. The physician should then separate the jaws with the aid of a 
mouth gag and explore the post-nasal space with his index finger. In the 
absence of a gag a clean cork or the handle of a spoon protected by gauze 
can be used to separate the jaws. 

If the child is very uuruly it is wiser to pin a sheet securely across 
the arms and examine in the dorsal position. 




Fig. 128. — Typical Adenoid Face in a Cretin. 
(Original.) 



1 British Medical Journal, 1887, p. 459. 

2 Sajous's Annual, 1888, vol. iii, p. 278. 



PLATE XYI 




Chronic Enlarged Tonsils and Associated Congested Throat, very frequently 

seen. ( Original. ) 




A case of Granular Pharyngitis. Large masses could be palpated in the 
rhino-pharynx. (Original.) 



ADENOID VEGETATIONS. 



413 



The physician can best make the examination by standing directly 
behind the child. 

Differential Diagnosis. — In making a diagnosis of adenoids in infants 
we must depend upon the inability to nurse properly and noisy mouth 
breathing. However, many other cases of noisy mouth breathing should be 
excluded. These briefly mentioned are: — 

1. Congenital, as : — 

Diminution in size or occlusion of one or both nostrils. 
Highly arched palate or deformity of soft palate. 
Distortion of cervical 

vertebrae. 
Atelectasis. 

2. Constitutional, as: — 

Syphilis. 
Lymphatism. 
Tuberculosis. 
Lithsemia. 

3. Other conditions, such as : — 

Acute rhinitis. 
Eectopharyngeal ab- 
scess. 
Disturbances of diges- 
tion. 
Paralysis of soft palate 

or pharynx. 
Diphtheria, especially 
nasal. 

These have to be carefully considered. These conditions may exist 
with adenoids, but when alone may cause symptoms similar to those occa- 
sioned by the presence of the hypertrophied tissue, so an operation may 
not result in the promised cure. In infants the examining finger, on 
account of its size, is out of the question, and the rhinoscopic mirror cannot 
be employed. To be absolutely certain the curette must establish the diag- 
nosis. 

. Prognosis. — The disorders arising from the presence of adenoids are: 
Eepeated attacks of coryza, chronic rhinitis, arrest of nasal development, 
nasal stenosis, and mouth breathing, with the associated mental listlessness. 
There is a tendency to bronchitis, to spasmodic croup and asthma. Children 
with adenoids usually have very poor appetites. There is an associated 




Fig. 129. — Digital Method of Exploring 

the Rhino-pharynx for Adenoids. 

(Original.) 



414 DISEASES OF THE NOSE AND THROAT. 

gastric catarrh. Some authors 1 state that measles, scarlet fever, and ear 
troubles are more frequently found in children where adenoids exist. Their 
presence is therefore a menace and they certainly invite infection. 

Treatment. — It is best to use an anaesthetic, as most children with 
adenoids are of a neurotic temperament. Be sure the child has neither 
heart nor kidney trouble before deciding upon an anaesthetic. If either 
condition exists, operate without an anaesthetic. 

A rapid anaesthetic in children is chloroform. Some authors advise 
the use. of nitrous oxide followed by ether as the best means of producing 
anaesthesia. Deep anaesthesia is uncalled for, as in that condition the cough 
reflex would be abolished. It is better to do the operation completely rather 
than put a child to the pain and discomfort of repeated sittings. Two or 
more sittings may be necessary if the child is not anaesthetized. The evening 
before the operation a 1-grain dose of calomel or a wineglass of citrate of 
magnesia has a beneficial effect on the bowels. The position of the child 
during the operation is. of great importance. Some operators prefer the 
head over the end of the table. Butlin 2 says the patient should lie on the 
side with the thighs flexed, the head a little forward on a low pillow. 

The Operation. — The Gottstein curette or its modification is best 
adapted to work in the antero-posterior diameter of the naso-pharynx. The 
Lowenberg forceps or its modification is used to grasp the mass and is 
preferred by many operators. 

With the curette the portion removed is apt to be lost and might even 
drop into the larynx, although it is the safest instrument to use with very 
young children. The best type of forceps is the Graedle or its modification 
by Concannon. This forceps has an extensive cutting edge, hence tearing 
is unnecessary. 

Operating Without an Anaesthetic. — The child should be placed in an 
upright position and held by an assistant. A mouth gag is used, and the 
closed forceps is introduced. The forceps is then opened widely and 
pressed well upward and behind. The mass is seized and the forceps with- 
drawn. The finger should always be introduced to be sure of the location 
and extent of any remaining masses. The latter can be removed with the 
finger, curette, or with smaller forceps. 

If the Gottstein curette is used it should be carried well up into the 
vault, carrying the soft palate forward; then it should be brought down 
with a bold sweep, to the vault of the pharynx. The steel nail is frequently 
advised by some operators as a means of removing adenoids. In spite of the 
most careful treatment 3 adenoids will frequently recur. 



1 Centralblatt, vol. i, p. 278. 

2 Lancet, vol. i, 1893, p. 363. 

8 W. K. Simpson February 13, 1902. 



PHARYNGITIS. 41 5 

Haemorrhages After Operation. — The local application of diluted 
peroxide of hydrogen, or MonselPs solution undiluted, is sufficient to control 
any ordinary haemorrhage. If, however, it is a case of haemophilia or pro- 
fuse bleeding, then the subcutaneous injection of 30 cubic centimeters 
sterile horse serum into the thigh or abdomen will control the bleeding. 

Thromboplastine, obtainable at the Eesearch Laboratory of the Xew 
York Board of Health, has recently been recommended by Hess. It is 
markedly haemostatic and somewhat antiseptic in action, and should be ap- 
plied locally for a few minutes to bleeding surface by means of cotton or 
gauze. If applications do not stop the bleeding, inject some of the clear 
solution into the site of the haemorrhage. 

For gastric or intestinal haemorrhage, the contents, of 1 vial (20 cubic 
centimeters) should be diluted with 8 ounces of water and taken by mouth. 
This may be given several times in the course of the day. Plugging the 
nostril with gauze saturated with thromboplastine is very efficacious in 
haemorrhage caused by exfoliation of diphtheritic membrane. This has 
been used by me at the Willard Parker Hospital with excellent result. 

Codliver-oil and malt extract are among the restoratives indicated for 
the after-treatment. The most important part of the after-treatment con- 
sists in the strict application of hygienic measures. The child should be 
placed in a room in which there is fresh air. windows open night and day. 
If a child is old enough we should teach it how to breathe. Out-of-door 
exercise should be insisted upon. Deep inspiration and expiration, and 
pulmonary gymnastics are just as important as attention to the food. Milk, 
meat, eggs, cereals, and fruits should be ordered, depending on the age and 
requirements of the case. 

Pharyngitis. 

The proximity of the pharynx to the tonsils renders this portion of 
the body very prone to harbor pathogenic bacteria. Infections therefore 
spread from the tonsils to the pharynx or from the uvula to the pharynx. 
In the article on tonsillitis I refer to this region as an avenue for infection 
through which tubercle bacilli may enter the lymph channels and set up a 
posterior basic meningitis. The diplococcus intracellularis can also enter 
the pharynx and by this channel set up a cerebrospinal meningitis. The 
pharynx is therefore an important part of the body to be inspected when 
obscure febrile conditions exist. 

Treatment. — Local applications of dilute Lugol's solution applied to 
the retropharynx once only by means of a cotton swab, and a spray of 
DobelPs solution after feeding and at night before retiring is a good means 
of destroying pathogenic bacteria in influenza or in catarrhal infections. 
During an epidemic it is good to employ the Dobell spray as a prophylactic. 



416 DISEASES OF THE NOSE AND THROAT. 

Ketrophakyxgeal Abscess (Ketropharyngeal Lymph Adenitis). 

This condition may be due to mechanical irritation or to direct infec- 
tion. The most common forms met with in children are evidently due to : — 

1. Local infection. 

2. Abscess caused by a tubercular infection or where caries of the 
cervical vertebrae exists. This latter condition we meet in older children. 
It is usually a sequel to the specific infections., and may follow scarlet fever, 
measlesj or diphtheria. It is most frequently associated with influenza and 
tuberculosis. Eachitic and syphilitic children are predisposed to this dis- 
ease. Catarrhal affections of the upper air passages also invite this" disease. 

Pathology. — The retropharyngeal lymph nodes are described (Simon) 
as forming a chain on each side of the median line between the pharyngeal 
and prevertebral muscles; these undergo atrophy after the third year. 
Sometimes adenoids will cause a swelling of the glands, giving rise to fever, 
but they will not suppurate. At other times the swelling of the retro- 
pharyngeal lymph nodes will' be associated with external cervical adenitis. 
It is important to recognize this condition owing to. the serious nature of 
the disease. 

Symptoms. — This affection usually develops very suddenly; the infant 
will refuse the breast or have trouble in swallowing. The food is most 
commonly regurgitated through the nose. Such infants will have labored 
mouth breathing. The head is thrown back, there is severe dyspnoea, occa- 
sionally asphyxia — laryngeal stenosis due to pressure of the abscess on the 
larynx, interfering with respiration. There is a peculiar snoring sound. 
With the index finger in the throat the soft fluctuating tumor can be felt. 
On examining the throat with a good light the bulging of the pharyngeal 
wall will be noticed. 

The temperature will range from 102° to "103° F., sometimes higher. 

Diagnosis. — The diagnosis should be made with the finger, by a careful 
palpation of the post-nasal and pharyngeal spaces. Mouth breathing due 
to adenoids will not cause sudden symptoms of suffocation. The sudden- 
ness of interference with respiration points to the development of an abscess. 
The following cases will illustrate this condition: — 

Case I. — An infant about fifteen months old was brought to my office by Dr. J. 
Martinson. The history was loss of appetite, regurgitating of food through the nos- 
trils, mouth breathing, and bulging of the pharyngeal wall. Temperature, 101° F. 
Cervical glands enlarged. The diagnosis of retropharyngeal abscess was made. An 
incision made in the abscess liberated the pus. The abscess cavity was cleansed 
with a 1 to 2000 bichloride solution. The child recovered. 

Case II. — A nursing infant, less than 1 year old, seen with Dr. J. Brandeis, suf- 
fered with retropharyngeal abscess. The treatment consisted in hot fomentations. 
When fluctuation was detected, an incision was made with a curved bistoury; the 
lower half of the blade was protected with cotton. After the incision the wound 



SPASMODIC LARYNGITIS. 



417 



was enlarged by introducing and separating the blades of a polypus forceps. The 
child recovered. 



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Fig. 130. — Temperature Chart from a Case of Retropharyngeal Abscess. 

(Original.) 

Treatment. — Some children require local applications. Antiphlogis- 
tine is a convenient local application until suppuration is established. Flax- 
seed poultices are sometimes well borne. 

No time should be lost if pus is present. The abscess cavity should 
be opened and the pus liberated. To prevent the pus flowing into the 
trachea, it is best to keep the head well forward. The use of a gag is not 
necessary if the tongue is depressed and the incision made with a small- 
bladed knife similar to a tenotome. After the pus is evacuated the parts 
should be cleansed with a 1 per cent, carbolic solution or a 1 to 2000 
bichloride solution, and the wound treated on general aseptic principles. 
Restorative treatment will consist in giving codliver-oil, hypophosphites, 
and last, but not least, food and fresh air. 



Spasmodic Laryngitis (Catarrhal 'Croup: Spasmodic Croup). 

This form of acute catarrhal spasm was first: described by Goodhart. 
The disease is simply an acute catarrhal inflammation associated with a 
severe spasm of the larynx. Infants under six months of age are rarely 
affected, and until 5 years the disease is most common. It occurs as fre- 
quently in well-nourished as in frail rachitic children. 

Catarrhal or spasmodic croup is frequently the result of hypersecretion 
in the naso-pharynx. When croup appears suddenly it should not be feared, 
especially so if the child was well during the day. It simply results from 
post-nasal secretions accumulating while the child lies on its back. Such 



418 DISEASES OF THE NOSE AND THROAT. 

croupous attacks will always yield to a good emetic dose of syrup of ipecac. 
Such children while awake suffer from the irritation of the secretion and 
swallow the same by day. A point to remember in this connection is that 
croup which is fatal or serious comes on very slowly and cannot be per- 
manently benefited by giving an emetic. 

Symptoms. — The symptoms are similar to those of laryngeal diph- 
theria. It is at times very difficult to differentiate catarrhal spasm of the 
larynx from diphtheritic croup. It is frequently found in infants with 
adenoid vegetations and post-nasal catarrh. An inflamed uvula, diseased 
tonsils, and pharyngeal catarrh are among the contributing factors. The 
mucous membrane is red and swollen. At first it is dry, but afterward it is 
covered with a watery mucous secretion. The catarrh may begin in the 
subglottic portion of the larynx and may be associated with oedema of 




Fig. 131.— Oil Atomizer. 

mucous membrane. It usually follows catarrh of the nose and pharynx, or 
it may be an extension of the disease from the bronchi. 

Children suffering from this form of croup will usually have repeated 
attacks of the same. The slightest exposure to cold and irritation by dust 
are among the exciting causes. 

After an attack of rhinitis lasting one or more days, the child will 
suddenly awaken at night with a hoarse, barking cough and the face will 
be extremely congested. The attack terminates by a long, noisy, high- 
pitched inspiration. 

On inspiration we note deep recession of the suprasternal fossa, the 
supraclavicular spaces, and the epigastrium. There is also depression of 
the intercostal spaces and the walls of the chest. The pulse-rate will be 
greatly accelerated. The temperature rarely rises over 102° F., although 
in some instances it may reach 103° F. Owing to the dyspnoea, children 
will usually gasp and try to sit up. The forehead and sometimes- the 



SPASMODIC LARYNGITIS. 



419 



whole body will be covered with large beads of perspiration after an attack 
of laryngeal spasm. 

Prognosis. — This is invariably good. A point to remember is that 
when croup appears suddenly, it is of a mild type resulting from catarrhal 
trouble. The dangerous form of croup comes on very- slowly, and in this 
type we must always look for diphtheria as a causative factor. 

Treatment. — In the treatment of diseases affecting the air passages we 
aim, roughly speaking, at two things: — ■ 

First. — To relieve the cough. 

Second. — To cure the disease. 




Fig. 132. — Steam Atomizer. 



Directions for Using a Steam Atomizer. — Put the liquid to be atomized 
in the cup D. Fill the boiler F about one-half full of water. Fill the 
lamp I with alcohol (use nothing but alcohol in the lamp), and after 
lighting it place it under the boiler. As soon as the water boils the medi- 
cated steam will be thrown out through the tube E, and can be inhaled 
through the shield A. 

Local Treatment. 

B Table salt 1 drachm 

Warm water 1 pint 

Or:— 

B Bicarb, of soda 1 drachm 

Warm water 1 pint 



420 DISEASES OF THE NOSE AND THROAT. 

Or:— 

I£ Tr. ferri chloridi 1 drachm 

Glycerine 1 ounce 

Water 1 ounce 

Or:— 

B Menthol . 5 parts 

Alboline 100 parts 

Or:— 

I£ Menthol 5 parts 

Paroleine 100 parts 

Either of the above solutions can be used in the form of a spray every 
two or three hours. This lubrication soothes the mucous membrane. 
Guaiacol, 2 per cent, solution, dissolved in alboline, can also be used. 

1$ Balsam of Peru % drachm 

Oil of eucalyptus y% drachm 

M. Sig. : Dissolve in 2 drachms of alcohol. A teaspoonful into a pint of 
boiling water, to be used in the form of a spray, by means of a steam atomizer. 
(Fig. 133.) 

Local applications of iodine and glycerine are frequently valuable: — 

IJ Iodine 3 grains 

Glycerine 1 ounce 

Kali iodide , 5 grains 

M. Sig. : Apply with a cotton swab, on larynx. Once daily. 

When this catarrh persists, a single application of the following will 
frequently abort an acute attack: — 

I£ Argenti nitrici 10 grains 

Aquae destillatse 1 ounce 

M. Sig.: Apply cautiously over the larynx. 

Emetics. — The most rapid method of relieving catarrhal accumula- 
tions is in giving an emetic. The choice of the same depends on indi- 
vidual experience. A safe and harmless emetic, quite rapid in action, is a 
teaspoonful of syrup of ipecac. The same dose may be repeated in half an 
hour if not effectual. Syr. scillas comp., commonly known as Cox's hive 
syrup, in teaspoonful doses, is also a mild drug, producing emesis. Mustard 
water and sulphate of zinc are also useful. Tartar emetic in 1 / 10 -grain 
doses, gradually increased, is valuable. My favorite emetic is sulphate of 
copper, 1-grain doses, with y 2 ounce or less of water. This usually produces 
an instantaneous effect. 

When children are obstinate and will not swallow, a V, 50 -grain or 1 / 25 - 
grain tablet of apomorphia, given hypodermically, may be repeated in ten 
or fifteen minutes if necessary. This is a convenient and rapid means of 
producing emesis. Emesis should not be repeated oftener than once in 
twenty-four hours, -and then always with due regard to the condition of a 
child. 



NIGHT COUGH. 



421 



Inhalations of steam impregnated with turpentine or pine-needle oil 
have served me very well. For producing this steam a croup kettle or 

a steam atomizer may be used. 

The steam loosens the viscid 
secretion and can be used every hour 
or less often, depending on the 
urgency of the case. 

Foreign Bodies in the Larynx. 

Foreign bodies such as fish- 
bones or particles of food are occa- 
sionally aspirated into the larynx, 
causing coughing and irritation. In 
some cases larjmgeal stenosis and 
symptoms of asphyxia result. No 
time should be lost in commencing 
treatment, owing to the danger of 
suffocation. 

The hypodermic injection of 
apomorphia ( 1 / 50 grain) until emesis 
is produced, or syrup of ipecac, 
several teaspoonfuls given by mouth, 
will occasionally dislodge the foreign 
body. If this is not successful a laryngologist should be sent for. A 
physician who is inexperienced with the larynx should refrain from pro- 
longed attempts to dislodge the foreign body, as in most cases only harm 
can result therefrom. If asphyxia threatens, tracheotomy should be per- 
formed. Those experienced with intubation should first try the effects of 
the large caliber tube known as the foreign-body tube (see chapter on 
"Intubation"). 

Coughs of Reflex Origin. 
Night Cough. 

A very troublesome form of cough is frequently heard at night. The 
history given is that the child is quite well during the day, but has a dis- 
tressing cough at night. 

The position of the child on its back permits naso-pharyngeal accu- 
mulations to stagnate; hence, this cough occurs when the child is on its 
back. Very young children do not expectorate, nor can they clean the 
nose. . 

Diagnosis. — A history of cough at night only points to naso-pharyn- 
geal disease. As a rule adenoids and chronic tonsillitis or pharyngitis 




Fig. 133...— Croup Kettle. 



422 DISEASES OF THE NOSE AND THROAT. 

should be suspected. The absence of fever and the freedom from cough 
during the day indicate a local catarrh which gravitates when the child 
is on its back. 

Treatment. — If adenoids are present they should be removed. Naso- 
pharyngeal catarrh should be treated by local applications of y 2 per cent, of 
iodine and glycerine solution. The naso-pharynx should be washed by 
means of a douche every morning and evening. - A weak solution of 
boracic acid or bicarbonate of soda is very serviceable. In persistent 
catarrh codliver-oil should be given. 

Spasmodic Cough (Pseudo-pertussis). 

I have previously described a cough which occurs in children having 
catarrh of the upper air passages ; sometimes this night cough is paroxysmal 
in character and the spasm resembles whooping-cough. 

Cause. 5 — The accumulation of the mucus in the region of the arytenoids 
and the vocal cords sets up a spasm of the glottis, resulting in attacks of 
suffocation. 

Symptoms. — A hoarse or barking cough, appearing in spasms with an 
interval of rest, is usually heard. The cough is frequently followed by vom- 
iting. The temperature is rarely above normal. - 

Diagnosis. — The absence of the cough by day and the appearance of 
the cough in spasms when the infant is placed on its back always point 
to a local throat condition of a non-inflammatory character. 

Treatment. — Eemove the cause if any is apparent. Locally, astrin- 
gents are indicated. Eestorative treatment, consisting of iron and Fowler's 
solution, will sometimes permanently benefit the child. 

Useless Cough. 

Thompson and MacCoy, of Philadelphia; Francis Warner, of London, 
and Emil Mayer, of New York, describe an irritating hacking cough in 
children. Such children do not suffer with fever, but have a poor appetite, 
are thin and irritable. Warner studied a series of 22,000 children in 
schools, and he attributes this condition not to peripheral irritation, in- 
testinal worms, nor to any disease of the tonsils or pharynx, but to un- 
balanced central nerve action. 

Keflex Cough. 

In post-nasal catarrh we frequently have a profuse discharge which, 
by irritating the pharynx, causes a cough. This cough frequently resembles 
that of an acute bronchitis. The examination of the lungs in such cases 
is usually negative. It is therefore advisable to examine the nose and 
throat in every case of cough. 



CHAPTEE II. 
DISEASES OF THE BRONCHL LUNGS, AND PLEUEA. 

The Lungs. * 

The lungs in children occupy the same position as in adult life. The 
trachea of the young child is larger in comparison than in the adult; so 
also the bronchi are larger than in the adult. They occupy more space and 
are more numerous than in the adult, but the air-cells are much smaller. 
I have described in detail the method of examination of the thorax in the 
article on "The Respiration in the New-born Baby." 

The Diaphragm. 

The diaphragm occupies a higher position in children than in adults. 
Dwight studied a series of frozen sections and found the diaphragm in the 
infant corresponding to the eighth and ninth dorsal vertebrae. 

POINTS TO BE XOTED IX THE DIAGNOSIS OF DISEASES OF THE LUNGS. 

AUSCULTATION. 

Acute catarrhal bronchitis: Sibilant and sonorous rales. Large and 
small bubbling rales. 

Capillary bronchitis: Sibilant, subcrepitant rales. 

Asthma: Sibilant, wheezing, sonorous breathing. 

Emphysema: Eespirations diminished, absent, or prolonged. Low- 
pitched expiration. 

(Edema: Bilateral, subcrepitant rales. 

Pneumonia: (1) Crepitant rales; (2) bronchial breathing and bron- 
chophony; (3) broncho-vesicular breathing, crepitant, subcrepitant, and 
bubbling rales. 

Pleurisy: Friction sound with each respiratory act, best heard with 
inspiration. If the child controls the movements of the lung and keeps 
the pleural surfaces apart, then no friction sound is heard. 

Subacute pleurisy: Friction, absence of vesicular murmur, and vocal 
resonance. 

Fluid and air in pleural sac: Eespiratory murmur absent, amphoric 
breathing above, all sound absent below, splashing rales. 



1 Acute tuberculosis, tubercular pneumonia, and lobar pneumonia are described 
in Part VII, in the "Acute Infectious Diseases." 

(423) 



424 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

Tuberculosis: Long, high-pitched expiration, breathing feeble, vocal 
resonance increased, adventitious rales, later bronchial breathing, bron- 
chophony. 

Tuberculosis, second stage: Cavernous breathing, amphoric breathing, 
gurgles, metallic echo. 

PERCUSSION RESONANCE. 

Vesicular: Uncomplicated lung. 

Dullness: Lung with increased proportion of solids. 

Flatness: Solids, fluids. 

Tympanitic: Large body of air. 

Vesiculotympanitic: Lung with increased proportion of air. 

Amphoric: Empt}^ -cavity with tense walls. ' , 

Cracked-pot: Cavity with flaccid walls. 

RHYTHM. 

Normal rhythm: Eegular succession of the respiratory acts. 
Interrupted rhythm: Slight deposit in lung. 
Divided rhythm: Want of elasticity in lung. 
Prolonged expiration: Want of elasticity in lung. 

BREATHING. 

Vesicular: Uncomplicated lung. 

Bronchial: Consolidated lung; compressed lung. 

Broncho-vesicular: Moderate consolidation, moderate compression. 

Cavernous: Flaccid cavity-walls. 

Amphoric: Tense cavity-walls. 

Exaggerated: Vicarious respiration. 

Diminished: Plastic exudation, want of elasticity. 

Absent: Fluid, air. 

VOCAL RESONANCE. 

Normal: Voice through normal chest. 
Bronchophony : Voice through consolidation. 
Amphoric: Voice in a cavity. 
JEgophony: Voice in compressed lung. 
Pectoriloquy : Articulate voice in cavity; in consolidation. 
Whispering pectoriloquy : Whispered articulation in cavity; in con- 
solidation. 

Cavernous whisper: Ill-defined articulation in cavity. 



BRONCHITIS. 425 

Bronchitis (Bronchial Catarrh; Acute Bronchitis). 

Bronchitis, commonly known as bronchial catarrh, is one of the most 
frequent diseases of infancy and childhood. It frequently follows nasal 
catarrh, phar} r ngeal catarrh, or catarrh extending from the trachea. 

Etiology. — There are certain predisposing factors which favor the 
development of this disease. Children with deficient nutrition, suffering 
with anaemia, and those with a weakened framework having rickets, are 
more susceptible to this disease. Children affected with catarrh of the 
upper air passages frequently invite an extension of this inflammatory 
process. 

Bacteriology. — The pathogenic bacteria found in the bronchi are staprry- 
lococci, streptococci, colon bacilli, and diphtheria bacilli. The bacteria 
most frequently seen are the diplococci of pneumonia and streptococci; in 
addition to these the bacillus of influenza frequently gives rise to bron- 
chitis. Other germs found were bacillus pyocyaneus and encapsulated ba- 
cilli. Eitchie 1 states that the above micro-organisms were rarely found 
alone, but always associated. He does not believe that a definite germ is the 
causative agent. These same micro-organisms under different conditions 
frequently enter the alveoli and produce pneumonia. 

' Pathology. — The anatomical changes noted in bronchitis are the same, 
irrespective of the cause. The disease may be limited to the large bronchial 
tubes or may extend into the finest ramifications. This tendency to extend 
into the capillaries is greater in children and still more so in infants. The 
accumulation of the catarrhal products in the smaller tubes adds a gravity 
of its own to the situation. It is well to emphasize this peculiar tendency 
of the trouble in those of tender age. 2 

On making a cross-section of the lung a muco-purulent discharge oozes 
from the bronchi. The same thick purulent matter can be forced out of 
the smaller tubes when compressing the lung between the fingers. The 
microscopic examination shows intense congestion of the superficial blood- 
vessels. Frequently there is a serous infiltration of the bronchial mucous 
membrane. 

When the infection extends into the smallest bronchi it is called "capil- 
lary bronchitis." Williams calls it "suffocative," owing to the severe symp- 
toms which develop. 

Capillary bronchitis is always accompanied by some alveolar catarrh 
and frequently passes on to a distinct broncho-pneumonia. Infectious secre- 
tions in the larger bronchi are sometimes sucked into the smaller bronchi 



i Journal of Pathology and Bacteriology, 1900, vii, 1-21. 

2 Christopher : Article on "Bronchitis," "American Text-Book on Diseases of 
Children." 



426 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

and frequently cause an inflammation of the lobule. A plug of mucus 
frequently acts as a valve in a bronchus, permitting some air to escape 
during expiration and preventing the entrance of air during inspiration. 

When all the air is expelled the lobule may collapse. This condition 
is known as atelectasis pulmonum. This condition is favored when the 
thorough expansion of the air tubes is interfered with. It is also favored 
by congestion, thickening of the mucous membrane, and the gummy secre- 
tions produced by bronchitis. 

It, moreover, accompanies those cases in which the position is not fre- 
quently changed. It is seen in rachitic deformities of the thorax. The 
most frequent place for this condition is at the border of the lungs. The 
collapsed area is of a dark-red or purple color and shows a uniform red 
surface on section. It sinks in water, but can be insufflated unless inflam- 
mation has already begun (Williams). 

Hachford has shown that disease of the lymphatic system is a factor 
in producing malnutrition in children. In children having the latter con- 
dition we must not be surprised if we have a persistent bronchial catarrh 
baffling the ordinary method of treatment. 

Symptoms and Diagnosis. — The symptoms vary with the severity of the 
disease. In mild cases the temperature rises to about 101° F. at night; in 
severer cases the temperature will reach 102° and even 103° F. The 
respirations are quickened and labored and the pulse is accelerated. When 
the temperature is subnormal in rachitic children, then such low temperature 
should be looked upon as a grave symptom. On auscultation sibilant rales 
are heard anteriorly, but more prominent posteriorly. 

As the secretion from the mucous membrane begins, the sibili give 
place to loose mucous rales. Graves's point is worth noting, that "the 
more numerous the sounds heard at any one point to which the stethoscope 
is applied, the smaller the bronchi involved." 

Much stress should not be laid on the sputum or the character of the 
expectoration. Children under 5 years rarely or never expectorate. The 
pulmonic resonance is usually normal. If the attack is a mild one, as the 
above-named symptoms would seem to indicate, then the symptoms will 
subside under palliative treatment. The greatest attention should be be- 
stowed on the pulse. 

A pulse-rate between 120 and 130 in a young child should be looked 
upon favorably. If the pulse is suddenly accelerated and reaches 140 
to 160 and the respirations are increased to 60 or 80 per minute, then a 
broncho-pneumonia should be suspected. Bear in mind that the normal 
ratio of respiration to pulse is about 1 to J/.; when this is disturbed so that 
the ratio is 1 to 2, or even 1 to 3, we should suspect pneumonia. 

Prognosis. — This varies according to the severity of the symptoms and 
the condition of the infant before it was taken sick. Children having a 



BRONCHITIS. 427 

cachectic condition or those having syphilis will certainly have a severer 
type of infection than children not so affected. In subnormal conditions 
bronchitis will frequently leave some traces, so that a "chronic bronchitis" 
is established. 

Treatment. — Hygienic Treatment: A child with bronchitis must be 
put to bed in a room having a temperature of 68° to 72° F. The air should 
be kept free from dust. The room must be properly ventilated. The pa- 
tient should be given as much sunshine as possible. Dark, ill-ventilated 
rooms will aggravate this condition. The body should be warmly clad — 
not too warm. Flannels should be worn next to the skin. A lukewarm 
sponge bath followed by friction with a coarse towel will stimulate the 
circulation and is very grateful to the child. If the child has a high tem- 
perature then a mustard foot bath should be ordered. 

Dietetic Treatment. — If the child takes a large amount of nourish- 
ment and assimilates the same, then the chances of restoring health are 
excellent. To rely on drugs and exclude food is to discard the most impor- 
tant part of the treatment. When the child refuses food by mouth, then 
rectal- feeding should be resorted to, so that the body is sufficiently nourished. 
It is a good plan to predigest milk for feeble infants; hence peptonized 
milk or whey and soups and broths should not be forgotten. The yolk of 
an egg beaten up with sherry wine for a child several years old will be 
found a convenient method for giving nourishment with stimulation. Water 
is very important in the treatment of this disease, especially so when there 
is a large amount of expectoration. 

Medicinal Treatment. — If the temperature is over 102° F., 1-drop 
doses of tincture of aconite, given every two hours, will be useful to reduce 
the fever. All children who cough swallow their mucus; hence a laxative 
or an emetic will be very serviceable. A teaspoonful of castor-oil, repeated 
in six hours, is very valuable. As an emetic a teaspoonful of syrup of 
ipecac, repeated in fifteen or twenty minutes if necessary, can be tried. 
When rapid emesis is desired, 1 grain of sulphate of copper dissolved in a 
teaspoonful of water will be very effective. This dose should not be re- 
peated more than once in two or three hours. Apomorphin in doses of 
Vioo grain, hypodermically, is a very effective emetic. This is indicated 
when the child refuses to take medicine. 

When the secretion is very viscid then steam inhalations will be very 
serviceable. The steam atomizer will be found very valuable in young 
children who cannot be held over moist vapor. Steam impregnated with 
beechwood creosote will be found a valuable means of loosening adherent 
mucus. It has a decided therapeutic effect. It is a powerful antiseptic. 

Restorative Treatment. — Eestorative treatment, such as using an emul- 
sion of codliver-oil or a malt extract, with or without iron, should not 
be omitted. 



428 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

Bronchial Asthma (Anaphylaxis). 

This is frequently called spasmodic asthma, owing to the spasmodic 
or paroxysmal dyspnoea associated with wheezing respiration. A pecul- 
iarity of this condition is that children appear to be perfectly well during 
the interval. This is frequently an anaphylactic phenomenon. 

Etiology. — Children having neurotic tendencies or those children of 
gouty families seem to be predisposed to this affection. Most writers on 
this subject believe that this condition is a vasomotor neurosis resulting from 
disturbed innervation of the pneumo-gastric or its ramifications, or the 
vasomotor nerves, causing a spasm of the muscles of the air passages. Hay 
fever is an affection which closely resembles bronchial asthma and alter- 
nates with it. 

Exciting causes are many; for example, enlarged bronchial glands, 
enlarged tonsils, adenoids, elongated uvula, and: hypertrophied turbinates. 
The inhalation of irritants, such as dust, may irritate and provoke a spasm. 
Not infrequently we find eczema existing at the same time or alternating 
with attacks of asthma. 

Gastro-intestinal disturbances are among the most frequent causes of 
asthmatic attacks. 

In many children various forms of protein food, such as white of egg 
albumin or serum albumin, will give rise to attacks of fever, wheezing of 
the chest, dyspnoea, and cyanosis. That a systemic poison has been intro- 
duced is very evident. This accounts for the alarming symptoms seen in 
many children after an injection of antitoxin. This is an anaphylactic 
phenomenon. 

Symptoms. — Without warning, a spasm or shortening of breath comes 
on, most frequently at night. There is usually such oppression and dis- 
tressed breathing that the child must sit up. Frequently the distress is so 
great that the child will grasp any object within reach. The shoulders are 
elevated and the head thrown back so that the accessory muscles of respira- 
tion are brought into play. The face assumes an anxious expression, and 
later becomes cyanotic. The eyes are prominent and the alas nasi widely 
dilated. A cold, clammy perspiration is usually present. The respirations 
are loud and wheezing, and are rarely increased in number. The inspiration 
is jerky, the expiration prolonged and laborious. There is very little or no 
thoracic expansion. The pulse is small and rapid. There is no fever, but 
we frequently have a subnormal temperature when the attack is prolonged. 
The extremities are frequently cold. After the attack there is exhaustion 
followed by sleep. An attack may last several hours, sometimes clays. 
Percussion of the chest during the paroxysm shows hyperresonance. There 
may be either diminution or prolongation of the vesicular murmur. The 
whole chest has sibilant and sonorous rales and wheezing sounds. 



BRONCHO-PNEUMONIA. 429 

The diagnosis is easy; we must exclude spasm of the glottis, croup, 
tracheal stenosis, and neoplasm in the larynx. The absence of fever will 
easily differentiate this condition from inflammatory respiratory diseases. 

The prognosis is usually good, especially so at the time of puberty. 
After an attack a careful examination of the lungs, the kidneys, the nose, 
and the throat should be made, and the exciting cause, if possible, should 
be noted. 

Treatment. — Fresh air to thoroughly oxygenate the lungs will afford 
relief. Do not use steam or heat of any kind. The application of two or 
three dry cups over the front and also over the back of the chest repeated 
every six hours will relieve the spasm. Surprising relief will be afforded 
by washing the colon with % teaspoonful of powdered ox gall in 1 pint of 
water. The latter will not only empty the colon of fasces and gas, but will 
also relieve the mechanical pressure on the diaphragm. The bowels should 
be kept loose by giving salines. Iodide of sodium in 1- to 5- grain doses 
should be given at least one month after the acute paroxysmal attacks have 
subsided. Codein, 1 / 5 grain for a child 5 years old, repeated every two 
hours, or Dover's powder, 1- to 2- grain doses, repeated every three hours 
until relief is afforded. Chloral hydrate with or without bromide of sodium 
in doses of 3 to 5 grains once only should be given at night to promote 
sleep and as an antispasmodic. 

The diet should consist of milk, thin soups, and fruit juices. All 
starchy foods, such as potatoes, bread, and cereals, should be omitted. 
After convalescence, fruit, vegetables, cheese, fish, and meat may be given. 

Broncho-pneumonia (Catarrhal Pneumonia or 
Lobular Pneumonia). 

This disease derives its name from the fact that it usually exists as 
an inflammatory condition affecting small areas of the alveoli of the lung. 
Contrary to lobar pneumonia, this catarrhal form does not terminate by 
a distinct crisis. This disease is usually a sequela to or a complication of 
whooping-cough, measles, diphtheria, or typhoid fever. It is this form 
which is most dreaded in diphtheria and which rarely ends favorably. It 
does not occur in distinct cycles, nor does it run a distinct course. One 
child may suffer with a broncho-pneumonia extending over ten days or 
two weeks. Another child with the same form and severity of the dis- 
ease may suffer from eight to ten weeks. Thus this disease may be con- 
sidered to be of a distinct wandering type. This disease does not depend 
on seasonal changes, although the greatest number of cases are met with 
in the spring and fall. 

Etiology. — By far the greatest number of catarrhal pneumonias may 
be found in those children offering the least resistance. Such cases are 



430 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

usually found in scrofulous, tuberculous, rachitic, and syphilitic children. 
When children have previously suffered from infections such as diphtheria, 
scarlet fever, measles, or typhoid fever, they are peculiarly predisposed to 
this secondary infection. It is for this latter reason that this disease is so 
fatal. In a series of fatal cases accompanying the various types of diph- 
theria seen by me at the Willard Parker Hospital, the large bulk suc- 
cumbed to this complication. This is due in a great measure to the 
devitalized condition of the body after a toxsemic infection, such as is 
found in diphtheria. Whether or not this disease is contagious has not 
been definitely settled. 

Bacteriology. — We know that various forms of germs, such as the 
staphylococcus, streptococcus, the diplococcus pneumonia (Friedlander), 
the diplococcus (Fraenkel), and bacterium coli, are among the specific 
micro-organisms which have been found intimately associated with this 
disease. 




Fig. 134. — Diplococcus Pneumoniae (Pneumococcus) : (a) single diplo- 
cocci; (&) the same in chains (Wolf's double stain). Leitz ocular I, oil 
immersion 1 / 12 . ( Lenhartz-Brooks. ) 

Pathological Anatomy. — The tracheal and bronchial mucous mem- 
brane is intensely congested, and the lumen of the smaller bronchi filled 
with thick muco-pus, which adheres to the surfaces and is as tenacious as 
a pseudo-membrane. The lung at the seat of infection shows dark brown 
or brownish-red, infiltrated areas, sometimes of a bluish-red color. The 
surface of the pleura contains large or small hemorrhagic areas. They 
resemble a sort of hepatization, brownish, grayish, or yellowish-gray in 
color, and in some areas have purulent infiltrations. Sometimes the inter- 
stitial tissue is associated in this condition with a tendency toward cica- 
tricial formation. Sometimes the alveoli have an emphysematous disten- 
tion. The whole process seems to be a bronchiolitis associated with cir- 



BRONCHOPNEUMONIA. 
I 



431 




Fig. 135. —Purulent (Suppurative) Bronchitis, Peribronchitis and Peri- 
bronchial Broncho-pneumonia in a Child Fifteen Months Old. (a) Puru- 
lent ; ( 6 ) mucoid bronchial contents ; ( c, c 1 ) bronchial epithelium infiltrated 
with round cells and partly desquamated ( c 1 ) ; ( d) bronchial wall contain- 
ing strongly congested blood-vessels and infiltrated with cells; (e) cellular 
infiltrated peribronchial and periarterial connective tissue; (f) septum be- 
tween the lung alveoli, partly infiltrated with cells; {g) fibrinous exudate 
in the alveoli; (h) alveoli filled with richly cellular, (i) with poorly cellular 
exudate; (Jc) transverse section of pulmonary arteries; (I) strongly con- 
gested bronchial, peribronchial and intra-acinous vessels. X 45. (Ziegler.) 

cumscribed atelectasis of the lung, from which, hyperemia and infiltrations 
of tissue result. 

Symptoms. — The symptoms are those of a bronchial catarrh and a 
bronchitis. Associated with this there is the usual fever, restlessness, and 
an increased frequency of respiration; there is also dyspnoea. There is a 
distinct cyanosis affecting not only the face and lips, but frequently the 
nails. There is an anxious expression to the countenance. The alas nasi 
participate in the respiration. The whole respiration seems to be super- 
ficial and brings every muscle into action. That there is an obstruction 
can easily be seen by an observation of the jugulum, by noticing the inter- 
costal space and also the epigastrium, which sinks at each inspiration. The 
frequency of respiration will sometimes be increased to 70 or 80 per min- 
ute, and it is very jerky in character. The pulse-rate will suddenly rise to 
140 or 160, and frequently in some cases to 200 per minute. The tem- 
perature may be as low as 100° F. and gradually rise one degree or more 
each day. It may reach 101° or 105° F. in the evening. The temperature 



432 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 



usually shows a morning remission of at least one or two and sometimes 
three degrees. 

Pictorial illustrations of broncho-pneumonia complicating measles and 
diphtheria will be found in their respective chapters. 

Physical Examination. — The physical examination of the thorax shows 
moist rales, sibilant or sonorous rales, or coarse mucous rales, at times dis- 
tinct bronchial breathing accompanied by a metallic sound. Percussion 
will usually show dullness over small areas. While this may be due to the 



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X Reintubated. 

Fig. 136. — Louis B. Aged 3 years. This very instructive case illus- 
trates the tolerance of the larynx for the intubation tube. In all, twenty 
intubations were performed. The chart illustrates the tube coughed up four 
times in one day, thus requiring four distinct intubations in twenty-four 
hours. In spite of the fact that the case was septic from the beginning, and 
that the child had a broncho-pneumonia, the case recovered. In order to 
retain the tube and prevent its being coughed up, the caliber was gradually 
increased from a number three until an eleven to twelve tube was used. 



localized area of consolidation, it is quite possible that the dullness may 
also be attributed to enlarged bronchial glands in this region. When the 
disease terminates favorably the temperature falls, the pulse assumes a 
more regular character, the heart sounds, which formerly were feeble, ap- 
pear louder, stronger, and rhythmic. The cough will be more frequent, 
the respiration less frequent and not so superficial. Children who formerly 
were apathetic now appear to notice everything, and appear very sensitive 



BRONCHO-PNEUMONIA. 433 

on being handled, and especially so during an examination. The physical 
signs of a diffused bronchitis and the diffused areas of moist rales associated 
with the localized areas of bronchial breathing disappear. The bronchial 
breathing which existed before now becomes vesicular in character. The 
pulse, which formerly was greatly accelerated, and the respiration, which was 
very frequent, now both return to their normal state. The whole character 
of this affection has no specific rule, but drags along without a distinct ter- 
mination, differing from that condition so well known and described as 
croupous pneumonia. It is not rare to note an apparent cessation of the 
inflammatory condition in the pulse, respiration, and temperature, and to 
find that new inflammation has begun with more active symptoms than has 
been just passed through. 

We can therefore see that a broncho-pneumonia frequently is a con- 
tinuance of an inflammation which spreads from portion to portion and 
from lobe to lobe, and thus devitalizes the system. The symptoms affecting 
the gastro-intestinal tract and those of the genito-urinary organs are the 
same as found in croupous pneumonia. 

The differential diagnosis between catarrhal and fibrous pneumonia can 
easily be made by a comparison of the course which these diseases run. 
Catarrhal pneumonia commences with symptoms of a bronchial catarrh or 
a bronchitis. These same symptoms remain during the course of the disease. 
The symptoms do not have those of an acute character which characterize 
croupous pneumonia, but rather assume a chronic appearance. The great 
danger consists in the development of pus infiltration in the lungs, and 
it is only by the rapid emaciation that symptoms of miliary tuberculosis 
can be suspected. 

We can differentiate catarrhal pneumonia from atalectasis by the total 
absence of fever in atalectic conditions. 

Prognosis and Course. — The prognosis depends on the origin of this 
disease. If, for example, broncho-pneumonia is a sequela to measles, diph- 
theria, whooping-cough, scarlet fever, or typhoid, and the child has passed 
through a severe infection in which the corpuscular elements of the blood 
have greatly suffered, then the prognosis is grave. If, on the other hand, 
this disease commences as a primary affection and the child is in a fairly 
well-nourished condition, then the prognosis is good. The prognosis will 
chiefly depend on the amount of food that can be properly assimilated and 
the care with which the case is nursed. The course is slow and tedious, 
and may develop tubercular pneumonia. 

The hygiene is very important in this condition. The prognosis of 
catarrhal pneumonia following whooping-cough, measles, or diphtheria will 
usually show that almost 70 per cent, of cases so affected are fatal. 

Treatment. — If the temperature is high, antipyretic remedies, such as 
the coal-tar products, are not indicated, owing to their well-known de- 

28 



434 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 



pressing effect upon the heart. The author has never "used them without 
seeing an ill effect. When they are used they should be combined with 
camphor or musk to counteract this well-known depression. The safest 
antipyretic measure in pulmonic affections is undoubtedly hydrotherapy. 
A cold compress applied over the thorax and repeated once every half -hour, 
not only acts as an antipyretic, but will stimulate the respiratory muscles 
and provoke deep inspirations. This will distend the smaller portions of 
the alveoli and will prevent atalectasis pulmonum. If there is very great 




Fig. 137. — Diagram for Pneumonia Jacket Opened at Side. 



Fig 




Diagram for Pneumonia Jacket Opened in Front. (Original.' 



dyspnoea owing to the presence of viscid secretions, then an emetic is indi- 
cated. One of our best emetics is sulphate of copper in 1-grain doses, re- 
peated in an hour if necessary. Another emetic and one which is less 
irritating than the above is syr. scillse comp. in y 2 to 1 teaspoonful doses, 
repeated every half-hour until the desired effect is produced. Syrup of 
ipecac in doses of one teaspoonful, repeated every fifteen to twenty minutes, 
is also serviceable. When a child has extreme dyspnoea and it is not wise to 
administer an emetic by mouth, then a hypodermic injection of 1 / 20 grain 
of apomorphia dissolved in five or ten minims of sterile water injected 
deeply into the subcutaneous cellular tissue will usually provoke emesis. 
If this dose is not effectual in fifteen or twenty minutes, then another 



BRONCHO-PNEUMOXIA. 435 

dose of apomorphia may be given. Tartar emetic in doses of 1 / 10 grain, 
in sweetened water, may be given every hour "until vomiting is produced. It 
is better not to change from one drug to another unless several doses have 
proven ineffectual. 

Flaxseed poultices are sometimes recommended when the secretions 
are very viscid. These have frequently proven efficacious in the hands 
of the author. In urgent dyspnoea great relief can be afforded by the appli- 
cation of dry cups over the affected areas of the lungs. 

A pneumonia jacket consisting of cheese cloth, which is worn next 
to the skin, then a layer of cotton-wool, and the whole covered with oiled 
silk or oiled muslin will serve to prevent chilling of the surface. Figs. 
137 and 138 show diagrams of these jackets. 

Internal diffusible stimulations, such as %-grain doses of carbonate 
of ammonia, repeated every hour, are serviceable. Liq. amnion, anisati, in 
doses of from 3 to 10 drops, repeated every hour, is one of our best dif- 
fusible stimulants. If symptoms of collapse appear then active alcoholic 
stimulation must be resorted to, such, for example, as champagne, brandy, 
whisky, or wine ad libitum. In addition thereto, a sinapism over the front 
and back of the chest and mustard foot baths may be required. Hypo- 
dermic medication will frequently be found necessary, especially if the 
heart's action is feeble. One two-hundredth of a grain of nitro-glycerine 
injected hypodermically or caffeine citrate will sometimes work well. 
Strychnine sulphate in doses of 1 / 200 grain, gradually increased, repeated 
every three or four hours or oftener, will stimulate the heart's action. An 
excellent heart stimulant is to give 1 drop of tincture of musk every hour. 

If the cough is very troublesome, especially at night, and the child is 
in a fair physical condition, then codeine in doses of 1 / 20 to V10 g ra in for 
a child 1 year old, repeated every two or three hours, will relieve. Dionin is 
a remedy that has been used by the writer with considerable success in the 
treatment of various forms of cough in doses of 1 / 20 grain, repeated every 
three or four hours, for a child 1 year old. 

Stimulating expectorants such as syrup of senega, in doses of from 10 
to 15 minims, may be advantageous. The vital point to remember is to 
support the system with nourishment. If the child will not take food 
per mouth, then rectal feeding consisting of nutrient enemas is demanded. 

Water should be given freely during the course of a broncho-pneumonia 
to stimulate the action of the kidneys. 

Pleurisy. 

An inflammation of the pleura is by no means rare in children. It 
is found very frequently post-mortem, although no evidence of the same 
existed intra vitam. It may be a primary condition. 

There are two distinct forms of pleurisy usually seen: 1. Pleuritis 



436 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 



sicca (dry pleurisy). 2. Pleuritis exudativa. The latter form can again 
be divided into (a) serous, (&) sero-purulent, (c) purulent, (d) hemor- 
rhagic. 

The last mentioned is a rare condition. It is seen in traumatic con- 
ditions, in haemophilia, and occasionally when tuberculosis is present. 

Dry Pleurisy. 

This form of pleurisy usually follows an exposure to cold, although 
it may follow as a secondary inflammation to the lung. There is usually 
an exudation of fibrin only. 



^a>yo\\toe.ftft& 




Fig. 139. — Fever Curve in a Case of Dry Pleurisy. (Original.) 



Pathology. — The pleura is swollen and thickened, and there is an exu- 
dation of fibrin. Adhesions frequently result from these bands of fibrin 
between the opposite pleural surfaces. The pleura loses its natural luster. 
When the process ceases and the lymph is absorbed, the condition is called 
"dry pleurisy." The fibrinous bands between the pleura costalis and pul- 
monalis usually leave permanent adhesions. 

Symptoms. — The disease is usually ushered in with high fever, which 
may reach 104°' or 105° F. Cough is usually present. It is a short, hack- 
ing, irritating cough. It is accompanied with pain. As a rule, children cry 
during each coughing paroxysm. A characteristic symptom often noted is 
that a child suffering with pleurisy usually places its hand over the affected 
area during a coughing paroxysm. This lends support to the ribs and 
relieves pain. There is no expectoration. A friction sound or a fine, crepi- 
tant rale is heard over the affected area. There is vesicular breathing. The 



PLEURISY WITH EFFUSION. 437 

percussion is rarely abnormal. The tongue is usually coated. The bowels 
are constipated. The urine is scanty. The surface of the body is dry and 
warm. There is usually a gradual increasing dyspnoea. The pulse-rate 
is increased; so also are the respirations. The symptoms resemble those 
of a pneumonia and can rarely be differentiated without a careful physical 
examination. There is usually pain on percussion over the affected area. 
The children do not wish to be handled, but prefer to lie quietly. 

The diagnosis depends on the symptoms above described. We must 
bear in mind the frequency with which pulmonary complications are asso- 
ciated. 

The prognosis is usually good, although adhesions frequently remain. 

Treatment. — Counter-irritation, such as cupping of the chest, the 
application of iodine over the affected area, or jointing with cantharidal 
collodion, acts well. Strapping the chest with broad straps of adhesive 
plaster or the application of a very tight fitting bandage seems to sup- 
port the chest and relieve the cough. Calomel is indicated, especially if 
constipation accompanies this condition. Iodide of sodium, with very small 
doses of codeine, may be given at regular intervals to relieve pain. A full 
dose of codeine or morphine may be given at night if the cough is distress- 
ing or the pain acute. I have given from 1 / 30 to 1 / 20 grain of morphine 
hypodermically to a child 2 years old to relieve a severe cough. 



Pleurisy with Effusion (Pleuritis Exudativa). 

This secondary form of pleurisy is usually a complication or an exten- 
sion of the infection in pneumonia. It is frequently met with in influenza 
and in infectious diseases. I have frequently seen pleurisy with effusion 
in the scarlet fever wards of the Eiverside Hospital. I have also seen pleu- 
risy complicating tuberculosis and rheumatism in children. 

Bacteriology. — In some cases the streptococcus, in others the staphy- 
lococcus, is present. A diplococcus has also been found and believed by 
some to be the cause of pleuritis. The pneumococcus has been found pres- 
ent, so that it is difficult to state which pathogenic microbe is the true cause 
of this condition. Whether this microbe gains entrance to the pleura from 
the lung by inhalation or through the skin, or whether the tonsil is the 
means of entrance of the pathogenic bacteria causing this disease, has not 
been definitely determined. We know that suppuration in other parts of 
the body, as, for example, in the abdomen or in the spine, can frequently 
carry microbic elements to the pleura and thus directly transmit the infec- 
tion. Pyogenic bacteria may be carried to the pleura through the lymph 
channels and by the circulation. 

Pathology. — This form of exudative pleurisy is the one most frequently 
encountered. We rarely find both sides involved, although a double pleu- 



438 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 



risy is by no means rare. The pathological condition is practically the same 
as described in the chapter on "Dry Pleurisy." In this condition we have 
more or less serous effusion. The serum may be clear, it may be bloody, or 
it may be turbid. Serous effusions found in a healthy child are usually 
absorbed. Adhesions are frequently left in this form of pleurisy. 
Symptoms. — The fever 



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140. — Fever Curve in a Case of Pleurisy 
with Effusion. (Original.) 



may be high or low. Fever 
and general malaise accom- 
panied by a hacking cough 
will frequently be the 
only symptoms. I have 
frequently seen children 
brought to my clinic with 
the history of a cough, no 
expectoration, anorexia, with 
general weakness and ema- 
ciation, in whom a pleurisy 
with a large effusion was 
detected.. 

Diagnosis. — The diag- 
nosis in very young children 
is at times difficult. It can 
only be made by a most careful physical examination of the chest. 

Physical Signs. — Before the effusion is marked, and during its absorp- 
tion friction sounds are heard over" the inflamed area. After the effusion 
is present there are no friction sounds. There are an absence of rales, dis- 
tant bronchial breathing, and flatness on percussion. There is diminished' 
breathing, so that the voice or the cry of the child will appear very distant. 
At the level of the fluid the voice has a tremulous sound, known as 
cegophony. There is a bulging of the intercostal spaces. The breathing is 
bronchial or tubular. Not infrequently the heart is displaced. A careful 
inspection of the chest will show that there is a loss of motion on the 
affected side during respiration. 

In some cases the diagnosis depends on the result of an exploratory 
puncture with a clean (aseptic) needle having a large caliber. One of the 
•best needles for this purpose is one similar to that used for the injection 
of antitoxin. A puncture should be made after washing the skin with 
soap and water followed by alcohol or ether. The needle is then inserted 
about one inch. Sometimes it is necessary to make several exploratory 
punctures in order to find the liquid, especially so in the encapsulated form 
of pleurisy, where a small area is involved. After withdrawing the liquid 
the character of the same should be determined by examining it under the 
microscope. If pus corpuscles are found we should insist on an operation, 



EMPYEMA. 



439 



as no other treatment will be satisfactory. Not infrequently a serous effu- 
sion will be absorbed by the exploratory puncture, so that the puncture is at 
times a very valuable therapeutic adjunct. 

Treatment. — Firm strapping of the chest with bands of adhesive 
plaster is useful; 5- to 15- grain doses of iodide of sodium, according to 
age, may be administered three times a day in milk, soup, or broth. Fresh 
air should be constantly permitted. If pain is absent gentle, but long 
inspirations and expirations (pulmonary gymnastics) are worth trying. 
By properly exercising the lungs we can stimulate nutrition to the parts 
and frequently assist in the absorption of an effusion. 




Fig. 141. — Diagrammatic Illustration of Heart and Lungs in a Left- 
sided Pleuritic Effusion, a. Heart. &. Compressed lung, area of bronchial 
breathing and crepitant rales, c. Effusion. (Original.) 



Dietetic Treatment. — No matter what form of treatment is instituted, 
nothing will avail so much as proper feeding. The dairy products — milk, 
eggs, and cheese — in conjunction with cereals and fruits, should form the 
bulk of the food ordered. Concentrated soups and broths are also useful. 



Empyema (Purulent Pleurisy). 

Etiology. — As a rule we find this disease following pneumonia or pleu- 
risy. It is a favorite complication of the infectious diseases, so that after 
a pneumonia in an acute infectious disease we must not be surprised to find 
an empyema. 



440 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

Bacteriology. — The bacteria most frequently found are the strepto- 
coccus, the staphylococcus, and the pneumococcus. Earely has the tubercle 
bacillus been found. 

Pathology. — The surface of the pleura is covered with fibrin and pus 
and the cavity filled with a purulent exudate, the result of this inflamma- 
tion. The pus settles to the bottom of the pleural sac. 

Not infrequently both pleurae become involved, although the rule is 
to find but one pleura or part of it affected. When not treated the pus may 
rupture into the lung or burrow externally through an intercostal space. 

Symptoms. — The most pronounced symptoms are flatness on percussion 
and diminished respiratory sounds. Sometimes they are totally absent. 
There is also a loss of the vocal fremitus. At the level of the fluid the voice 
has a tremulous quality known as cegophony. 

Above the fluid the breathing is broncho-vesicular due to the com- 
pressed lung. Pleurothotonos is sometimes seen. 

There is an absence of expansion of the chest on the affected side. 
When this condition exists on the left side it may displace the heart. 

I rely upon the examination of the blood, in addition to the physical 
signs given, as an important guide in determining the presence of pus in the 
system. See article and illustration of "Blood Reaction of Pus" in the 
chapter on "Blood." 

Diagnosis. — If the fever continues after a case of pneumonia, or pain 
in the chest persists accompanied by dypsncea, cough, and sweats, then 
empyema should be suspected. 

When the disease progresses the temperature frequently returns to 
normal or nearly so. The child shows symptoms of general exhaustion, 
emaciation, and is extremely anaemic. Diarrhoea is a frequent symptom in 
this condition. 

The physical signs above noted are usually positive. When there is 
any doubt, and in order to confirm the symptoms pointing to an empyema, 
an exploratory puncture should be made. 

If the needle is sterile and sharp and the surface to be punctured is 
rendered aseptic, then there is no risk in making one or more punctures to 
aid in establishing the diagnosis. 

Choice as to Where the Needle is to be Introduced. — My plan has always 
been to find by percussion the area having the greatest dullness or flatness, 
and insert the needle after noting the following : — 

Points to be Noted while Making an Exploratory Puncture. — The skin 
should be washed with soap and water, dried, and again washed with alcohol, 
and lastly with ether. The needle should be boiled about Ave minutes before 
being used. 

If the needle is introduced on the right side, due allowance must be 
made for dullness in the region occupied by the liver. Do not introduce 



EMPYEMA. 441 

the needle too near the region of the spine, but choose rather an intercostal 
space in the axillary line or preferably below the scapula on either side. 
If the needle is introduced on the left side do not push it too forcibly nor 
too deeply or haemorrhage may result. Sometimes the fluid is fibrinous and 
will not readily enter the caliber of the needle. If the needle is plunged 
too far and enters a dilated bronchus, due allowance must be made for a 
purulent secretion, which should not be mistaken for empyema. 




Fig. 142. — Illustrating a Severe Localized, Right-sided Empyema. Two 
ribs were resected. The child made a complete recovery. The thorax shows 
very slight deformity after the operation. (Original.) 

Prognosis. — This depends upon the general condition at the time of 
the operation. If the tubercle bacillus is found in the pus the prognosis is 
bad. The longer the disease existed the more doubtful the prognosis. If 
the condition is a sequela to a pneumonia or a pleurisy then the prognosis 
is good. 

Course. — The tendency of empyema in a child is to recovery. Out of 
20 cases operated by me, 18 recovered in four to five weeks. One case 
recovered after six months of continued surgical treatment, and was op- 
erated three times. One case was ill over two years, tubercle bacilli being 
found. This case belonged to the tuberculous type of empyema. 



442 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

Surgical Treatment. —When pus is located, the indication is to remove 
it. After painting the area with tincture of iodine an incision should be 
made at least two inches long through the skin, and parallel with the rib. 
If the pus is thin in character a simple intercostal incision carried into the 
pleura will evacuate the same. If the pus contains fibrinous coagula, it is 
better to resect one or two ribs. Care must be taken to preserve the 
periosteum in resecting the ribs. By this latter method we have complete 
drainage, and if the case is treated on general aseptic principles with 
drainage, gauze, and restorative treatment, the outcome is usually good. 

Points to be noted in empyema cases: — 

1. Anaesthetic. — Do not use general anaesthesia if cyanosis, marked 
dyspnoea, or other severe toxic symptoms are present. 

Local anaesthesia, such as chloride of ethyl or cocaine, can be used. 
I have frequently operated with the aid of chloride of ethyl. 

2. Regarding Antisepsis. — When pus is located we must resort to the 
usual details of asepsis and antisepsis. The instruments should be rendered 
thoroughly aseptic and the child should be given a bath on the day of 
operation in addition to a thorough scrubbing of the seat of operation. 

The physician, if a general practitioner, should not operate if he has 
been in contact with an acute infectious case; neither should he operate if 
he has a case of erysipelas or diphtheria under his care. 

While pus is being evacuated, turn the child from side to side, to empty 
the pleural cavity. If the heart's action is poor this should not be done. 

A large-sized drainage tube should be inserted into the wound. The 
pleural cavity should not be washed with any fluid. It is important to have 
a cross-section of rubber tube or a large safety pin attached to the drain- 
age tube; otherwise, as has already happened, the tube may be lost in the 
cavity. 

Excepting when large coagula are present, as in pneumococcus empyema, 
the syphon drainage (Kenyon method) may be recommended. This form 
of drainage is especially indicated in streptococcus empyema; however, this 
type is extremely rare in children. 

A male child, 4 years old, was brought to my office by Dr. M. Freid, with the 
following clinical history: The child's appetite is poor. He does not sleep well, and 
has a peculiar waddling gait. The left shoulder blade protrudes so that a decided 
deformity is noticeable. There was no further history. 

An examination of the child showed marked emaciation. Temperature 100V 6 o 
F., pulse 120, respiration 38, breathing labored, heart sounds weak but clear. On 
percussion there was marked dullness and flatness over the central and upper lobe 
of the lung on the left side. An exploratory puncture made about the eighth inter- 
costal space showed pus. Owing to the weakened state of the child, it was 
necessary to operate without an anaesthetic. Ethyl chloride was used, an incision 
made, and two ribs resected. Thorough drainage was maintained with the aid of a 
drainage tube, and, with the addition of restorative treatment, the case made an 
uneventful recovery. 



CHRONIC EMPYEMA. 



443 



Treatment. — The treatment consists in building up the system with 
tonics of iron, hypophosphites, codliver-oil, malt, sea-salt bathing, and 
fresh air, in addition to a nutritions diet, of which milk, eggs, and cereals 
should form the bulk. 

Stimulation will be urgently required. In other words, our aim should 
be to build up the body to withstand the shock of the operation, and at the 
same time to nourish and restore the general weakened condition. 

After-treatment. — Strict asepsis. Change dressings daily. Use clean 
drainage tube and fresh gauze. Eemember the danger of iodoform poison- 
ing in using large strips of iodoform gauze. 

Give nutritious food. Sometimes a change of air to the mountains or 
seashore will aid in recovery. 




Fig. 143. — James Apparatus for Expanding the Lungs in Empyema. 

Eemember that 10 per cent, of all cases in which a simple incision 
is made do not require after-treatment. Ninety per cent, of cases require 
resection of the ribs and frequently additional surgical treatment for chronic 
empyema. 

James Apparatus. — Pulmonary gymnastics, such as inspiration and 
expiration, should be frequently practised to aid in the expansion of the 
lung after an operation for empyema. A clever device is known as the 
James apparatus, by which a colored liquid can be blown from one bottle 
into another. This may be given to the child as a toy, and is very valuable 
as a means of producing deep inspiration and expiration. 



Chronic Empyema. 

Neglected cases or those of long standing frequently require additional 
treatment. Adhesions will frequently form, preventing the normal expan- 
sion of the lung. A small opening or sinus containing exuberant granula- 
tions will be seen. In some cases seen by me pus has oozed for months. In 
a case of this kind nothing will do as well as a radical operation such as 



444 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

Estlander recommended (thoracoplasty). The adhesions must be broken 
up and thorough drainage allowed. When such a radical operation is per- 
formed, deformity usually follows. These cases belong to the surgeon. 

Tubercular Empyema. 

This condition, while rare, has been seen by me twice during the last 
five years. It is found in families where tuberculosis exists. We must 
bear in mind that a tubercular empyema may be the complication of what 
was formerly a non- tubercular type. 

Environment and heredity play an important part in the etiology of 
this condition. Just as a tuberculosis may follow the broncho-pneumonia 
of measles, so I believe that tubercular empyema may also develop. The 
following case will illustrate this condition as seen by me in consultation 
in New York City: — ■ 

M. J., 5 years old, was referred to be by Dr. Mehrenlander, with a history of 
cough, fever, and emaciation. The diagnosis of empyema was made and an 
exploratory puncture showed the presence of pus. With the assistance of Dr. 
Mehrenlander I performed a thoracotomy. As there were thick, croupous masses, 
two ribs were resected and a drainage tube inserted. In this case the wound 
discharged several months and an examination of the pus showed the presence of 
tubercle bacilli. With the aid of fresh air and restoratives, such as codliver-oil, 
creosote carbonate, and special attention to the out-door life, the child recovered. 

Family History. — The child's father and mother are living. Their occupation 
is janitor and janitress in a tenement house. They receive in compensation for 
services free rent, so that gives them very unsanitary surroundings.. The bedrooms 
are dark and very unsanitary. An older brother, 17 years of age, has acute apical 
tuberculosis. This older brother when brought to me for a slight cough showed 
no visible evidence of disease; in fact, he appeared well nourished. His sputum con- 
tained tubercle bacilli. We therefore have in the two cases just described a tuber- 
cular empyema associated with family tuberculosis. The coexistence of empyema and 
a family history of tuberculosis strengthened my opinion that, living under the same 
unsanitary conditions and associating together, these cases were most probably 
transmitted or communicated. 

The excellent results which have been reported during the last few 
years by the treatment with an artificial pneumothorax, and the injections 
of nitrogen, lend encouragement in the treatment of this fatal disease. From 
my own experience I strongly favor this method in every case in which 
tuberculosis exists. 



PART VII. 

THE INFECTIOUS DISEASES. 



CHAPTER I. 



FEVER. 1 

This is a pathological process generally caused by the poisonous prod- 
ucts of bacteria, and characterized by a rise of temperature above the limit 
of the daily variation. It is further associated with an increase in the fre- 
quency of the heart and the respiratory movements, often with an increase 
in excretion of urea and ammonia in the urine and a diminution in the 
alkalies and C0 2 in the blood. 2 

Some authors state that the cause of fever is the action of bacterial 
poison or of other substances on the heat centers, and that antipyretics or 
drugs which reduce the temperature in fever, do so by restoring the centers 
to their normal state by preventing the development of the poisons, aiding 
their elimination, or antagonizing their action. Thus it has been stated 
(supporting the latter view) that if the basal ganglia have been cut off 
(by section of the pons) from their lower nervous connections, fever is no 
longer produced by injection of cultures of bacteria which readily cause it 
in an intact animal — while antipyrine has no influence on the temperature. 
These experiments were reported by Sawadowski. 

Some observers have been unable to find any clear evidence of heat 
centers ; that is, of localized portions of the central nervous system specially 
concerned in the regulation of the body temperature. 

It is almost certain that some pyrogenic or fever-producing agent — 
cocaine, for example — acts indirectly through the brain or cord, and likely 
others affect directly the activity of the tissues in general, just as some 
antipyretics or fever-reducing agents, such as quinine, seem to act imme- 
diately upon the heat-forming tissues, while antipyrine affects them through 
the nervous system. 

Variations in Temperature. 3 — The temperature of the body is not con- 
stant. It varies with the time of day, with eating, with age, somewhat 
with violent changes in the external temperature (hot or cold baths), and 
even possibly with sex. 



1 For treatment of fever, see pages 474 and 475. 

2 Stewart's Physiology, p. 443. Article on ''Animal Heat." 

3 The temperature as a diagnostic aid is described in Part I, page 11. 

(445) 



446 THE INFECTIOUS DISEASES. 

The lowest temperature is recorded between 2 and 6 a.m. The highest 
at 5 to 8 p.m. There is a corresponding fluctuation of pulse-rate at the same 
time of day. 

Taking of food increases the temperature, but not more than one-half 
of a degree in healthy individuals. Entrance of food into the body in- 
creases metabolic activity, no doubt through entrance of products of diges- 
tion into the blood. 

Sex. — Females usually have higher temperature than males. 

Relation of Age to Temperature. — There is a relative imperfection 
between heat regulation in old people and young children; thus, young 
children are more liable to sudden increase in temperature as well as to 
chills. A fit of crying will send up the temperature. Sudden fright (slam- 
ming a door) will send up the temperature (J. L. Smith). 

Mosso reports that the rectal temperature rose three degrees in a dog 
rendered helpless with injections of curare. When injections of strychnine 
were given, this latter (strychnine) no doubt irritated the nervous system. 
He found that the presence of food was enough to cause the rise in the 
temperature of the dog. 

Thus we find that the usual fever-causing factors are : — 

1. Toxins. 

2. Ferments. 

3. Products of waste which are absorbed in the lymphatics (detritus). 

We know that the regulation of the heat is brought about by the cen- 
tral nervous system, and we also know the influence brought about by the 
vasomotor (nervous) system in dilating and contracting the capillaries. 

The discovery of Aronsohn and Sachs, that by traumatism or irritation 
of the corpus striatum, an elevation of temperature is produced, is still 
a question, doubted by many distinguished observers. But it certainly 
does look as though a certain center or centers exist which influence the 
body temperature. 

Knowing then that other agencies besides disease cause an elevated 
temperature, the question arises : Are we justified in designating every rise 
of temperature as "fever"? Hardly. An elevation of temperature (above 
normal) should be designated as "hyperthermia." We know that the 
fever is caused by the absorption of infectious products which later cause 
a breaking down and loss of the red blood-corpuscles, breaking down of the 
tissues, and disintegration of albumin and its compounds, and produce 
symptoms pointing to distinct disorders in the human economy. Some 
authors have described fever under two headings or divisions: — 

1. Septic. 

2. Aseptic. 

As an example of a septic fever, we have that chronic poisoning of the 
human organism which takes place in chronic pulmonary tuberculosis, and 



FEVER. 447 

even in this latter toxaemic process we find sudden rises of temperature, 
which must be explained by emotional means, or rather by nervous causes. 
:In a tuberculous patient whose system is overwhelmed with toxins (chronic 
and continuous poisoning) we can readily understand why the thermic 
centers as well as all other centers could be easily influenced to cause a 
sudden rise in temperature responding to a slight emotion or fright. 

Let us now consider so-called "nervous" or, as it has been designated, 
'^hysterical fever." The latter term we owe to the French authors (Pomme, 
Toussot, Baillon, Eiviere). By this we mean a febrile condition which is 
not caused by any inflammatory or other disease agency, and which is 
found in either very nervous, neurasthenic, or hysterical patients. 

Broussois (France) opposed this theory and believed this condition 
due chiefly to inflammatory changes in the ovary and uterus. 

Briquet showed by careful examination the fallacy of the foregoing 
statements in a series of noteworthy investigations. 

In 1888 Chaveau, in Paris, wrote a careful dissertation called "Fievre 
Hysterique," and divided this condition into several distinct groups. A 
characteristic point is the absence of gastric disturbance (digestive), show- 
ing that it was not a malignant disturbance. 

Chaveau looked to the cause of his cases in an abnormal excitation of 
the thermic center in sensitive (nervous) individuals. An accompanying 
factor he believes to be either traumatic or psychic disturbances. 

Wunderlich (Germany) long ago called attention to the fact that 
hysteria influences the temperature, and that in hysterical neurosis we find 
sudden elevations of temperature. It is a remarkable fact and one noted 
by many others that one side of the body shows this high temperature 
without any pathological condition manifesting itself. 

Eosenthal (Vienna) found distinct localized areas of redness with 
marked rise of temperature in this area, but found no general febrile 
disturbance. The patient was decidedly hysterical. Strumpell agrees that 
he has found very high temperatures, irregularly, but believes the patients 
simulated their marked hysterical and irritable condition. 

Ewald (Berlin) agrees that hysterical patients can produce high fever 
by reason of their excitement. 

Hale White (England) doubts that the thermogenetic functions should 
cause high fever, and cites instances which were known as hysterical 
paralysis. 

Cleman reported in the Clinical Society of London, 1883, a case of 
hysterical fever showing the enormous temperature of 111° F. at various 
times. 

Hale White believed that a mistake in reading the thermometer was 



448 



THE INFECTIOUS DISEASES. 



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450 THE INFECTIOUS DISEASES. 

Ughetti believes hysterical fevers exist, and cites, as proof of the same, 
fever in course of hysteria, chorea, epilepsy, and Basedow's disease. 

The greatest scientific contribution on this subject has certainly been 
the work of A. Sarbo in the University of Psychiatrie and Nervous Dis- 
eases in Budapest. 1 He believes -as a result of experimental study that 
the causation of fever should be looked forward to in the "central nervous 
system," and that the experimental discoveries of the thermic and vaso- 
motor centers seem to confirm this. This author believes that fever which 
has no organic lesion as a cause should be called functional fever, which 
is a condition found in hysteria, the latter a functional neurosis. It is 
interesting to record that Debone increased the temperature by suggestion 
to 101.2° F., or 38.5° C. 

Krafft-Ebing records temperatures by suggestion as high as 106.4° F. 

Sarbo concludes by saying that from his clinical observations a distinct 
hysterical fever exists. 

Hysterical fever can simulate by its exacerbation and remission such 
diseases as typhoid, malaria, tuberculosis, and meningitis. 

Some years ago much was expected from the antipyretic drugs — anti- 
pyrin, acetanilid, and phenacetin; and if it could have been shown that 
they distinctly improved the condition of the fevered patient it would have 
been a strong argument against the view that pyrexia is a defensive mech- 
anism. 

When fever arises and a distinct diagnosis cannot be made, the child 
should be put on the expectant plan of treatment. This will consist in 
cleansing the gastro-intestinal tract, regulating the diet, and noting symp- 
toms as they arise. This is especially indicated when we believe the case 
to be, in the period of incubation, of an infectious disease. At such times 
the following recipe is a good antipyretic and will not depress the heart : — 

I£ Sweet spirit of niter 1% flui drachms 

Citrate of potassium 30 grains 

Syrup of lemon 4 fluidrachms 

Aqua^ r q. s. ad 2 fluidounces" 

A teaspoonful every three hours, for child 1 year old. 

I am indebted to Dr. William H. Guilfoy, Eegistrar of the New York 
Health Department, for many courtesies in the preparation of the statis- 
tics of the various infectious diseases. 

Bacterial Vaccines. 2 

The vaccine treatment of disease in children has many advocates. 
There are very many instances in which specific results may be attained ; on 



1 Published in the Archiv fur Psychiatrie in 1891. 

2 These vaccines are prepared in the Sherman laboratories of Detroit, and in 
the Mulford laboratories of Philadelphia. 



BACTERIAL VACCINES. 45 1 

the other hand, we should not be disappointed when we meet with failures. 
The following class of cases lend themselves to this form of treatment : — 

How to Procure an Autogenous Vaccine. — Clean the surface of the skin 
with alcohol or tincture of iodine. Make a small incision with a sterile 
bistoury into the furuncle and remove 1 drop of pus, to inoculate the 
surface of a blood-serum culture tube. Send to a laboratory to be placed in 
an incubator. From thirty-six to forty-eight hours' time is required to 
have a vaccine made. 

Stock Vaccine. — If too remote from a laboratory, a stock vaccine of the 
staphylococcus variety may be used with excellent results. 

Local infections, as well as general systemic infections with fever, do 
not contraindicate the use of these vaccines. They may be injected regard- 
less of the temperature. Surgical treatment, and general systemic treatment 
of the bowels, kidneys, etc., should be continued just as though no vaccine 
had been used. 

Streptococcus infections from the pleural cavity, as in empyema, or from 
the middle ear in acute otitis have been treated with vaccines. 

The consensus of opinion found amongst competent clinical observers 1 
is that the streptococcus vaccine has not the specific virtues, nor does the 
vaccine give the same benefit, obtained from the staphylococcus vaccine. 

An injection of 50,000,000 to 500,000,000 dead bacteria is usually 
given. Of all vaccine therapy, the most brilliant results have been obtained 
with autogenous vaccines or stock vaccine of staphylococci ; hence, in those 
diseases which owe their origin to a staphylococcus, vaccines should be used. 

In chronic suppurative processes in which subnormal conditions prevail, 
vaccine therapy will stimulate phagocytosis and thus aid in restoring normal 
conditions. 

In multiple furunculosis, in acne, and in otitis media due to the 
staplrylococcus, vaccine should be used. In post-operative empyema with 
low vitality and tendency to run a long course, vaccine therapy is indicated. 
In suppuration of the antrum of Highmore, or in recurring styes caused by 
staphylococci, vaccine therapy should be used. 

An injection of 50,000,000 bacteria constitutes the initial dose. The 
part is cleansed by tincture of iodine, and the injection given subcutaneously. 
Another injection of 50,000,000 bacteria should be given after three to five 
days, and if no improvement is noted at the end of ten days, then a third 
injection of 100,000,000 bacteria should be given. 

General Furunculosis. — A child 10 years of age was brought to my 
office with a series of furuncles that required incision. They healed after 
four or five days. Then new ones appeared. Surgical treatment was re- 
quired. In all, over a dozen had developed. I decided to have an autogenous 



1 Howland and Hoobler, Archives of Pediatrics, Sept., 1910. 



452 THE INFECTIOUS DISEASES. 

vaccine made. The pus was examined and proved to be staphylococcus 
pyogenes aureus. An injection of a vaccine containing 500,000,000 bacteria 
was given. These injections were repeated every other day until five were 
given. The child quickly recovered. These injections checked the develop- 
ment of new furuncles. 

Gonococcus Vaccine. — Injections of 50,000,00 to 100,000,000 bacteria 
of the gonococcus vaccine have been given by me daily until ten injections 
were given. No systemic reaction followed. The discharge lessened in 
some cases, it disappeared in others. The gonococcus however persisted. 

Typhoid Vaccine. — An injection of 25,000,000 typhoid bacilli may be 
given to a child, and repeated in one week, unless a severe reaction is noted. 
If fever occurs, wait ten days to two weeks before giving the second injec- 
tion. A third injection of 50,000,000 bacteria should be given ten days 
after the reaction following the second injection has subsided. 

Pertussis. — I have had excellent results with the vaccine made from 
cultures of the Bordet-Gengou bacillus, by the Health Department of New 
York City. 1 As a prophylactic three subcutaneous injections are usually 
given, one every third day. Children, 500 million, 1000 million and 2000 
million; adults, 1000 million, 2000 million and 3000 million. 

For curative purposes, four to five injections are usually given, one 
every second or third day. Children under one year should receive 250 
million, 500 million, 1000 million, 1500 million, 2000 million. Children 
over 1 year, 500 million, 1000 million, 2000 million and repeat last dose. As 
a rule this is sufficient, but, if no result is obtained, further injections may 
be tried as well as larger doses. 

A local reaction may occur and is without significance, disappearing in 
24 hours. A general reaction, which is rare, would indicate that the inter- 
vals between injection should be lengthened and dose more gradually 
increased. 

Erysipelas Vaccine. — My results with vaccine treatment in erysipelas 
are excellent. I have seen a severe erysipelas improve after an injection of 
50,000,000 bacteria the first day, 75,000,000 the second day, and 100,000,000 
the third day. In profound toxemia with temperature ranging between 103 
and 105 degrees I have injected from 50,000,000 to 100,000,000 bacteria of 
the erysipelas vaccine in an infant 1 year old. 2 The dose was repeated 
every other day. Five doses in all were given. 

Streptococcus Tonsillitis. — G-ive an injection of 50,000,000 bacteria. 
If no reaction follows, repeat the dose on the following day. If no improve- 
ment is noted, give 100,000,000 bacteria on the third day. 



1 Vaccine furnished by the courtesy of Dr. Krumwied. 

2 See clinical case in article on Erysipelas. 



BACTERIAL VACCINES. 



453 



Rabies Vaccine. — The Pasteur treatment has now been simplified and 
can be administered at home by simple vaccine injections. When a child 
has been bitten by a dog, no time should be lost, but the treatment imme- 
diately begun. The daily dose for injection is contained in an ampule. The 
treatment should be continued for twenty-one days. 

The New York Health Department sends out treatment by mail to 
physicians for their own patients. Full directions are sent in the mailing 



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Fig. 144. — Temperature chart, Case II. 



case. One-fourth of 1 per cent, of carbolic acid is added to the emulsion 
prepared as above for' the first three days' treatment, 20 per cent, glycerin 
is added to all other emulsions. The carbolic and glycerin are added as 
preservatives and are omitted when the vaccine is administered to patients 
at the laboratory. 

The Hygienic Laboratory at Washington also sends treatments by mail 
and a half-dozen manufacturing firms have followed suit. The results from 
the treatments sent seem to be equally as good as those from the treatments 
administered at the laboratory. 



454 THE INFECTIOUS DISEASES. 

Vaccine Treatment of Pneumonia. — Literature records many cases of 
pneumonia in which marked improvement followed one or more injec- 
tions of pneumococeus vaccine. My own experience with the vaccine has 
been good. I have nsed the heterogeneous variety, although in many cases 
an autogenous vaccine may be preferred. To procure an autogenous vaccine 
there are several difficulties encountered: First, the difficulty of procuring 
sputum from a child. Second, the time lost in waiting for a blood culture 
to grow, and then the preparation of a vaccine from the blood culture. This 
usually takes several days. When it is important to have an immediate 
effect, the stock vaccine should be used. 

In the sputum there may be found the pneumococeus and the strepto- 
coccus. Frequently the streptococcus, staphylococcus, and influenza bacillus 
are found. Because of this mixed infection, the pure pneumococeus vaccine 
alone does not exert the specific influence that we might expect from it. 

During the winter of 1914 I had occasion to see two unusually severe 
types of pneumonia. In one case an infant 13 months old received an in- 
jection of 1 cubic centimeter of the mixed influenza, pneumococeus, and 
streptococcus vaccine. The disease undoubtedly was cut short; the tempera- 
ture dropped from 105° F. to normal in three days. The physical signs 
gradually disappeared. Convalescence was undoubtedly hastened by the 
use of the vaccine. 

A second child, 3% years old, began with a severe influenza affecting 
the nose and throat, and follicular tonsillitis. The inflammatory condition 
extended and a broncho-pneumonia was discovered seven days after the 
onset. In this case an injection of 1 cubic centimeter of the mixed pneumo- 
coceus, streptococcus, and influenza bacillus was given. As no distinct 
improvement was noted, a second injection was given, twenty-four hours 
later, after which decided improvement was noted. The disease terminated 
by lysis. The child recovered. (See temperature chart, Fig. 144.) 

Vaccine treatment is especially indicated when fever is prolonged and 
resistance is poor. A marked leucocytosis usually follows these injections, 
thus proving that more resistance is given to the patient by such injection. 



CHAPTEE II. 
PERTUSSIS ( WHOOPING-COUGH ) . 

This acute infectious disease is caused by a specific micro-organism. 

Etiology. — The catarrhal type of child with hypertrophic tonsils, and 
especially the child with adenoid vegetations, is more susceptible to whoop- 
ing-cough. When the cervical lymph-glands are enlarged, due to an in- 
fection of the lymphatics, then this disease will enter more readily. The 
tuberculous child and the syphilitic child will offer less resistance to this 
disease than the normal child. 

Poor hygienic surroundings, and living in congested districts, where 
sunlight and fresh air are wanting, are factors that encourage the develop- 
ment of this infectious disease. Statistics have proven that a child arti- 
ficially fed will take this infection quicker than an infant brought up on 
human milk. 

Bacteriology. — In 1906 [Bordet and Gengou isolated a bacillus from 
the sputum of whooping-cough patients, but the complications of this disease 
are due to a mixed infection. Mallory and Hover 1 demonstrated that in 
pertussis there is a large accumulation of bacilli between the cilia of the 
respiratory epithelium, this interference with normal bacillary action hinder- 
ing removal of inhaled particles, and thus depriving the lungs of their most 
effective means of resisting invading bacteria. 

The Complement-Deviation Test. — A. Friedlander and E. A. Wagner 2 
state that the diagnosis can be made in the catarrhal, the paroxysmal, or the 
convalescent stages. 

Technique of Test. — A small amount of blood — about 15 to 20 drops — ■ 
are taken from the patient's ear, finger, or toe in small test-tubes, or in 
the Wright capillary tubes. Eor young children the great toe is very satis- 
factory. The blood is kept at room temperature, or placed in the in- 
cubator until coagulation has taken place. Serum is then separated more 
completely from the clot in the centrifuge. So far in the tests only fresh, 
active serum has been used. Two drops of the serum were used in each test. 

Hemolytic System. — The Noguchi system was used because of its ex- 
treme delicacy, and because of the small amounts of material, especially 
serum, required. In this system washed human corpuscles, 1 drop to 4 
cubic centimeters of salt water were used. 

Amboceptors. — The amboceptors employed were prepared according 
to the Noguchi method, the serum being dried on filter-paper. The com- 



1 Journal of Medical Research, Nov., 1912. 
2 Amer. Jour, of Dis. of Children, August, 1914. 

(455) 



456 THE INFECTIOUS DISEASES. 

plement was obtained in the usual way from guinea-pig dilution 1 to 40. 
Aside from the delicacy of this hemolytic system, it is of great value in 
working with children because of the very small quantity of blood required. 
It is not necessary to take blood from the veins, and the small quantity of 
blood required is easily obtained even from very young infants. 

Antigen. — This is the most important factor in the test. Subcultures 
were made on Borders medium and on ascitic fluid agar exclusively and 
the antigens were made as follows : Seventy-two hour growths were taken. 
The colonies, which were very tenacious, were scraped off the agar with a 
glass hook into sterile salt water. An emulsion was made and the bacteria 
again washed in salt water. It is important to do the second washing so 
as to rid the emulsion of any particles of agar. From this washed emulsion 
a standard suspension was made, and 0.1 to 0.2 cubic centimeters of this 
used in the tests. Throughout the test live bacteria were used. 

Controls. — In each test known normal and known positive controls were 
used. In each series of tests the hemolytic system was tried out in the 
usual manner, using a water bath at 37° C. for incubation. After primary 
incubation for half an hour the amount of amboceptor indicated by the 
preliminary test was added to our final test-tubes and the tubes again 
incubated in the water-bath. 

In 18 cases tested during the paroxysmal stage all gave positive re- 
actions. The reaction is not present in bronchitis. 

Diagnosis. — There are three stages to this disease : first, the catarrhal 
stage; second, the paroxysmal or spasmodic stage ; third, the stage of decline. 

In the catarrhal stage we are dealing with the symptoms of an irritant 
cough, with no fever, no vomiting, and very little expectoration. Such 
expectoration is of a glistening or glairy character. The cough is severe at 
night, and milder during the day. As a rule, the appetite is poor, and the 
child shows nervous symptoms, such as irritability by day and restlessness at 
night. In some cases there is an intestinal catarrh associated, and the stool 
contains shreds of mucus. 

In the spasmodic stage, usually the second or third week after an in- 
fection, the cough appears in spasms and ends in a "whoop." The cough 
is usually linked together and followed by a long inspiration which has a 
distinct "whoop." During this coughing paroxysm the face assumes a 
reddish or cyanotic appearance. Many paroxysms end in vomiting. Violent 
paroxysms frequently cause nose-bleeding or haemoptysis. When the 
paroxysms have continued for a week or more, the face assumes a characteris- 
tic puffy appearance. An intense capillary congestion will frequently be 
seen on the skin and also by an examination of the conjunctival mucous 
membrane. 

The paroxysmal stage may last from four to ten weeks, although I 
have seen severe cases in which a distinct "whoop" continued for six months. 



PERTUSSIS (WHOOPING-COUGH). 457 

It is a good plan to count the number of paroxysms in twenty-four hours, 
and by comparison with the previous week we can judge of improvement, if 
the frequency of the spasm is lessened. Xot infrequently 20 to 50 paroxysms 
may occur in twenty-four hours. 

During a severe paroxysm, the forcible pushing forward of the tongue 
stretches the frenum and brings it into contact with the teeth, frequently 
resulting in ulceration. 

The symptoms of the third stage, or stage of decline, correspond to 
those of the first stage, although there is extreme exhaustion from the force 
and frequency of the cough. From the inanition due to the vomiting and 
the loss of sleep caused by the paroxysmal cough, cardiac weakness must be 
expected. The heart sounds are feeble and muffled. A systolic blowing 
murmur is usually heard at the apex and may remain for many months. 
The pulse is small, low tension, and frequently irregular, owing to the heart 
strain. Owing to the disturbance of the circulation, in addition to the 
inanition, cold extremities are usually noted. 

Differential Diagnosis. — In the early stage of pertussis it is quite diffi- 
cult to differentiate it from bronchitis. An examination of the blood should 
be made, and if a marked lymphocytosis is present then the diagnosis is 
positive. If the cough is paroxysmal in character and most frequent at 
night, we should suspect pertussis. 

The frequency of the cough and the intensity of the spasm, which grows 
worse from day to day, is characteristic of whooping-cough. When a child 
with pertussis is taken into the fresh air the spasms as a rule are less marked. 

If after exposure to a case of whooping-cough, fourteen days have 
elapsed, and no cough has developed, we can consider the child free from 
infection. 

In Isew York City children suffering from whooping-cough are ex- 
cluded from school until the whoop has entirely disappeared, which, 
generally speaking, means from six weeks to two months. 

Complications. — The most frequent complication seen by me is broncho- 
pneumonia. The prolonged duration of the cough and the broncho- 
pneumonia frequently end in tuberculosis. Pleurisy with or without 
effusion is occasionally encountered. Atelectasis involving one or more 
lobes of the lung is occasionally seen in rickety children. The heart suffers 
because it is subjected to a severe strain. An irregular or intermitting 
pulse may frequently be noted because of the exhaustion from the frequency 
of the spells, the inanition resulting from vomiting, and the loss of sleep 
due to the cough. Emphysema is occasionally met with. Asphyxia is one 
of the dangers during continued paroxysms. When convulsions occur 
during the course of this disease the outcome is usually fatal. Paralysis 
has been described after a severe paroxysm. Such paralysis may be due to 
an intracranial haemorrhage. The frequency of haemorrhage from violent 



458 THE INFECTIOUS DISEASES. 

coughing paroxysms is one of the great dangers of this disease. Epistaxis is 
quite common. The sclera of both eyes is the seat of frequent haemorrhages. 
Haemoptysis and haematemesis are frequently noted. Cerebral haemor- 
rhage resulting in unilateral or bilateral paralysis is occasionally met with. 
Hemiplegia or paraplegia following pertussis must be looked upon as a very 
grave complication, although not necessarily fatal. Strabismus has been 
reported in this disease following a severe cerebral haemorrhage. Loss of 
vision and partial or complete aphasia have been reported. Hematuria with 
and without nephritis is occasionally met with during the course of this 
disease. The functional derangement of the kidneys may be due to the 
long duration of the disease. Diabetes mellitus has been seen by me which 
persisted more than two years. 

Prognosis and Course. — The outcome of any case depends on three 
factors: First, the proper nutrition of the body by frequent feeding. If 
food is ejected, then more food must be given. Second, the amount of rest 
obtained to restore the exhaustion from the violent coughing. Third, the 
prevention, if possible, of complications. If complications exist, such as an 
empyema, treatment should be instituted as though it were not a case of 
pertussis. 

The course of the disease can be shortened by supporting the strength 
of the body with food and by aiding nature in securing rest at night. 

Treatment. — Medicinal: There is no specific in the treatment of this 
disease. Phenacetin 2 to 5 grains, or antipyrin in the same dosage, re- 
peated every two hours until relief is afforded, will modify the cough. For 
relief at night codein should be given liberally ; % g r &in gradually increased 
to % grain may be given to a child 2 to 5 years old, and repeated every two 
to three hours until the cough lessens. Cautiously given, the dose of codein 
may gradually be increased until % to % grain per dose is given. No 
systemic disturbance will be noted. 

Another valuable drug is sulphate of morphia ; no more than 1 / 30 grain 
increased to 1 / 16 grain should be given every four hours to a child 2 to 5 
years old. Great care should be exercised and the nurse invariably cautioned 
regarding the dangers of this drug. 

Heroin in doses of 1 / 24: grain increased to 1 / 12 or % grain, may be 
repeated every four hours, in some palatable menstruum like syrup of Tolu. 

If sleep is disturbed and the cough is severe, 5 to 10 grains of sodium 
bromide combined with 2 to 3 grains of chloral hydrate may be repeated 
every three hours. 

Tussol, phenocoll, lactophenin, euchinine, paster in, and antispasmin 
are drugs recommended by enthusiasts. They have been tried by me with 
indifferent results ; in some cases they are of value, but in most cases useless. 

Fischl, of Prag, strongly advises the inunction of antitussin by thor- 
ough massage into the thorax. This remedy owes its therapeutic value to the 



PERTUSSIS (WHOOPING-COUGH). 459 

presence of fluorin vapors which are liberated. In addition thereto he 
recommends the oil of cypress, this aromatic oil to be dropped on the pillow 
at night, or on gauze worn around the neck by day. 

Bromoform has served in very many cases, sometimes with marked 
benefit; in other cases no benefit was noted. The dose of bromoform is from 
2 to 5 drops in syrup, three times a day. Belladonna and atropin have 
their advocates. Owing to the extreme dryness and the erythematous flush 
following the administration of belladonna, it must be used with caution. 
My results do not warrant recommending the same. Dionin (Merck), in 
doses of Ybq to V25 grain cautiously increased, may be given every three 
hours to a 2-year-old child. 

To relieve the distress caused by the coughing paroxysms, an abdominal 
support, very snug fitting, affords relief. In like manner a plaster bandage 
snugly applied around the ribs will give additional support to the thorax 
and frequently modify intense paroxysms. Strips of belladonna plaster en- 
circling the chest may do some good. Such plaster may be left in position 
from several days to one week. 

The injection of a vaccine prepared from the Bordet bacillus made 
by Dr. G-. H. Sherman has many advocates. 

Fresh Air. — The spasms can be shortened by keeping the child in the 
open air; the roof is the best place in a city. Such open-air treatment to 
be continued night and day during the mild weather. During stormy 
weather the windows should be kept wide open. In winter with the body 
properly clad the fresh, cool air will do more to restore the child's health 
than all drugs combined. 

Food. — During the spasmodic stage the child's nutrition is lessened 
because of the frequent vomit. Small meals at frequent intervals are indi- 
cated. Yolk of egg in milk or orange juice, calf's foot or chicken jelly, raw 
scraped beef, custard, buttermilk, cheese, and ice-cream should form the 
bulk of the diet. My plan is to feed a portion of one or two of the above- 
named foods every two to three hours, thus giving ample nutrition. 

Restoratives. — After the spasmodic stage subsides and the cough is 
lessened, Fowler's solution 2 to 5 drops should be given three times a day. 
Codliver oil each teaspoonful containing 1 / 200 grain of phosphorus should be 
given three times a day after meals. If the oil is well borne it should be 
continued throughout the winter; if not, give Fellow's syrup of hypo- 
phosphites. 



CHAPTER III. 
PNEUMONIA (LOBAR OR CROUPOUS). 

This acute infectious disease is frequently seen in infancy and child- 
hood. It is caused by the invasion of a specific micro-organism, the pneu- 
mococcus; also known as the micrococcus lanceolatus. The disease rarely 
exists longer than from six to nine days. It terminates by crisis. It is a 
self-limited disease. In some cases it may terminate by lysis. 

Etiology.— This disease most frequently exists in children between the 
ages of 5 and 10 years. Baginsky states that, among 173 pneumonias 
studied by him, he found the following : — 

6 children less than 1 year old. 
28 children between 1 and 2 years. 
58 children between 2 and 5 years. 
63 children between 5 and 10 years. 
18 children between 10 and 14 years. 

We find on studying the above cases that the greater number of pneu- 
monias are found in children between the ages of 5 and 10 years. Schles- 
inger studied a series of cases of pneumonia and found that 96 cases affected 
the right lung as against 66 cases affecting the left lung. He also found on 
the right side of the lung : — 

22 cases affecting the upper lobe. 

7 cases affecting the middle lobe. 
32 cases affecting the lower lobe. 

On the left side of the lung: — 

11 cases affecting the upper lobe. 
cases affecting the middle lobe. 
47 cases affecting the lower lobe. 

Thus he found that the lower lobes on both sides of the lungs were 
more frequently affected than the upper lobes, and that the seat of pneu- 
monia in children corresponded with the investigations of von Dusch, 
showing that the most frequent seat of pneumonia of the lobar variety is 
certainly found at the base of the lower lobe of the left lung. This is an 
important diagnostic point when symptoms point to the development of 
pneumonia. 
(460) 



PNEUMONIA. 



461 



«-v« 





&*£<& 



Fig. 145. — Focal Metastatic Hematogenous Streptococcus Pneumonia 
Following Angina, (a) Pneumonic focus with streptococci (blue) ; inflamed 
surrounding tissue. X 80. (Ziegler.) 




Fig. 146. — Croupous Pneumonia. Red hepatization of the lung (alco- 
hol, carmine, fibrin-stain), (a) Infiltrated alveolar septa; (6) fibrinous 
exudate; (c) red blood-cells. X 200. (Ziegler.) 



462 THE INFECTIOUS DISEASES. 

Bacteriology. — The disease originates by an invasion of a specific micro- 
organism first described by A. Fraenkel. Other investigators, among 
them Klebs, Ziehl, and C. Friedlander, have found various micro-organisms 
in the lymph channels, and in the alveoli of pneumonic lungs. Some of 
these germs have been encapsulated. It remained, however, for Fraenkel to 
find the specific germ causing this disease. Weichselbaum was one of the 
first to prove the positive specific infection of the Fraenkel diplococcus. 
This diplococcus is found not only in the lungs, but frequently also in the 
meninges, in the nasal secretions from the nasal mucous membrane, and at 
times in the kidneys. Wherever this micro-organism is found there is 
usually an inflammatory condition resulting therefrom. 

When this specific germ was injected into animals, pneumonia always 
resulted. 

Pathology. — The infection is usually caused by the pneumococcus. In 
pleuro-pneumonia both the visceral and the parietal pleura are coated with 
a large layer of yellowish-green fibrin, . in thick, shaggy masses, by which the 
lung is adherent to the chest-wall, the diaphragm, and the pericardium. 
The exudation varies between one-eighth and one-half inch in thickness. 
It can often be stripped from the lung or scraped from the chest-wall by the 
handful. In its meshes small pockets may form, which contain only a few 
drops or sometimes a drachm of pus, or, less frequently, serum. This is the 
condition in which the lung is usually found when death has occurred at the 
height of the disease. If the process has lasted longer, larger collections of 
pus may be present. The lung itself shows the usual changes of pneumonia, 
and if there has been any considerable accumulation of fluid there are in 
addition the evidences of compression. 

With pleuro-pneumonia of the left side, the pericardium is occasionally 
involved. This was seen in two of my cases, the lesions closely resembling 
those of the pleura. In two cases there was also meningitis, and in one 
peritonitis, the exudation in all cases having the same characteristics (Holt). 

There are four stages which have an important bearing on the progress 
and on the outcome of this disease: first, the stage of congestion; second, 
the stage of red hepatization; third, the stage of gray hepatization, and, 
fourth, the stage of defervescence or resolution. 

Varieties of Pneumonia. 

Abortive Pneumonia. — This form of pneumonia is frequently disbe- 
lieved by some clinical observers. At times children who are in apparent 
good health will suddenly have intense fever, cough, and on physical ex- 
amination show distinct symptoms of pneumonia. Frequently dullness on 
percussion in addition to bronchial breathing will be plainly made out. In 
two, possibly three days, the whole clinical picture will be changed and the 



WANDERING PNEUMONIA. 



463 




Fig. 147. — -Case of Influenza and Pneumonia. The disease spread from 
lobe to lobe, so that the child passed through several distinct inflammations. 
This fprm is known as Pneumonia Migrans (Wandering Type). Careful 
dieting, aided by stimulation, and the fever treated by cold compresses and 
cold colon flushings aided recovery. (Original.) 



464 THE INFECTIOUS DISEASES. 

child will appear to be normal. This form of pneumonia has been recog- 
nized and studied by other authors, but Baginsky maintains that the dis- 
ease is of the abortive type. It is quite possible that some of these symptoms 
have been latent for several days prior to the detection of the physical signs, 
and thus what appears to be an abortive form of pneumonia covering two 
or three days may easily have existed for several days prior to the detection 
of the same. 

Pneumonia Gastrica. — This form of the disease is one in which the 
symptoms of vomiting and diarrhoea predominate, and hence it is known 
as the gastric type of pneumonia. While the lungs will show the usual 
symptoms of a croupous pneumonia, the tongue, stomach, and bowels will 
present symptoms of an intense inflammatory condition of the digestive 
tract. Not infrequently jaundice may be present. 

The conjunctival mucous membrane may be pigmented from the pres- 
ence of bile. The secretions may also show biliary pigmentation. Herpes 
may appear on the upper lip, thus showing that there is an- intense inflam- 
matory condition affecting primarily the digestive tract. 

Wandering Pneumonia ("Pneumonia Migrans"). — This form of pneu- 
monia is met with quite frequently. The symptoms are those common to 
lobar pneumonia, as chills, fever, and the usual physical symptoms of a 
consolidated lung in this condition. The name is derived from its tendency 
to spread from lobe to lobe. The infection usually commences in one lobe 
and spreads to the second, to the third, and frequently when the crisis 
has taken place the disease commences with full force in another lobe and 
may continue so for several weeks. That this form of pneumonia is very 
serious can be easily imagined. A child, having suffered with acute lobar 
pneumonia and passed its crisis with an already weakened heart, has 
again to pass through the second pneumonia and frequently through a third 
and a fourth, and must certainly have great vitality in order to recover from 
the depression caused thereby. 

Pleuro-pneumonia. — It is rare to find lobar pneumonia without an as- 
sociated inflammation of the pulmonary pleura. Not infrequently with a 
severe type of broncho-pneumonia covering large areas of consolidation there 
is a coexisting inflammation of the pleura. It is difficult to state at times 
which lesion began first, whether it was the pleurisy or the pneumonia, in a 
given case of pleuro-pneumonia. 

Cerebral Pneumonia. — This type of the disease is one which is very 
frequently met with in which the symptoms of pneumonia are chiefly com- 
plicated by meningeal symptoms; thus clonic spasms or convulsions are 
usually present. In addition thereto there is vomiting, constipation, head- 
ache, opisthotonos, delirium, stupor, irregularity of the pulse, and, later 
on in the disease, coma. In some cases paralysis is liable to occur. 



CEREBRAL PNEUMONIA. 465 

Symptoms and Course. — The disease is usually ushered in with con- 
vulsions. At times vomiting and diarrhoea may be the first symptoms 
noticed. Chills are very rarely seen in children. The cheeks are usually 
very red and show the characteristic flush so well known in adult pneu- 
monia. The respirations are increased, the pulse is accelerated, and the 
temperature rises. One of the most important diagnostic points and one 
upon which I lay great stress is the "ratio between the pulse and respira- 
tion/' Normally the ratio is 1 to 4, and when this ratio is increased, as, 
for example, when there are 60 respirations and 140 pulse beats, then the 
ratio of 1 to 4, which normally existed, is certainly disturbed. By this 
disturbed ratio alone we can frequently make a diagnosis by the process of 
exclusion. Especially is this true in those cases of "central pneumonia" in 
which the disease develops in the center of the lung and gradually spreads 
toward the periphery. When such central pneumonia exists, the physical 
signs will be so masked that bronchial breathing will be hardly discern- 
ible. The temperature will suddenly rife to 102°, 103°, and frequently 
to 105° F. The temperature in rachitic children will sometimes rise 
to 106° and 10?° F. It is this class of cases that shows the most severe 
form of depression from irritation of the thermic centers. In these rachitic 
children we usually note that the invasion of pneumonia begins with a con- 
vulsion or a series of convulsions. 

Children old enough will frequently complain of abdominal pains. 
Thus we must not be misled by gastric or gastro-intestinal symptoms until 
we can exclude the lungs as the seat of the disease. The physical sign most 
commonly associated with this disease is dullness on percussion over the 
affected area of the lung. In addition thereto there will be bronchial breath- 
ing. If the child cries, a loud bronchophony will be heard. There will also 
be an increased vocal fremitus. These symptoms usually remain the same 
for a few days, although they may increase in intensity. 

Between the sixth and the ninth day, rarely earlier and very rarely 
later, a crisis takes place, in which the temperature will suddenly drop to 
normal. The patient will be covered with a profuse perspiration; the 
pulse, which formerly was full, bounding and accelerated, will be found 
smaller and less frequent. The former flush which existed will give place 
to a distinct pallor of the skin, and the observing physician will note a 
decided change in the patient. This condition, known as the crisis, may 
come on suddenly or gradually. In some cases the fever drops slowly — 
i.e., by lysis — until normal is reached. 

Pulse. — The pulse-rate is one which is a very important factor in con- 
nection with this disease. While it may be 1.20 and be quite regular in 
action, it is not uncommon to find the pulse-rate 140, and even 160. The 
frequency of the pulse is not as important a factor in determining the 
progress of this disease as is the character of the pulse. Thus, to illus- 

30 



466 THE INFECTIOUS DISEASES. 

trate, if a pulse is not frequent, but is weak and arrhythmic, such a patient 
should be regarded as in imminent danger and requiring very frequent and 
careful stimulation. A condition of collapse may be looked for in such a 
patient, and treatment directed to the prevention of the same is indicated. 
If the pulse-rate has been 120, and it suddenly increases to 140 or more, 
then some complication must be suspected and the child carefully exam- 
ined to determine the cause of this sudden increase of the pulse-rate. 

Respiration. — The whole respiratory condition is superficial and seems 
to call the accessory respiratory muscles into play. When the respiration 
is above 40 per minute, the diagnosis is usually very positive. 

Lack of Expansion. — rA lack of expansion may also be noticed. It 
involves the whole of the affected side and is not limited to the sub- 
clavicular region. In pneumonia this lack of expansion in the subclavicular 
region is marked, even though the inflammatory process is situated at the 
base. It can be observed as early as the first day, and lasts throughout the 
entire course of the disease. This early appearance of the sign is of especial 
importance, since the physical signs of involvement of the lung are so 
frequently delayed in cases of infantile pneumonia. 

The sign is best elicited in the dorsal position, and is easily seen on the 
exposed chest in quick respiration. 

One writer says he has recognized by this sign alone pneumonia occur- 
ring in a supposed case of appendicitis, and also has discovered pneumonia 
complicating typhoid and influenza. 

The Temperature. — A rise of temperature usually implies the invasion 
of the specific micro-organism and hence is one of the earliest symptoms 
of this disease. It usually rises from 102° to 105° F., and remains so until 
the crisis. There is, however, a morning remission; thus we find the tem- 
perature about one degree lower in the morning than we do in the evening. 
In pneumonia we frequently find a condition known as the "procrisis." This 
procntical stage exists one day before the crisis, as a rule. The temperature 
will suddenly fall to normal on the day preceding the crisis. It has a valu- 
able prognostic significance, showing that the inflammatory stage has now 
terminated. 

In Fleuro-pneumonia. — Symptoms: The friction sound is the charac- 
teristic feature throughout. In addition to the pleuritic friction sounds, 
the symptoms of pneumonia, such as bronchial breathing and bronchophony, 
are found. There isi marked dullness and frequently flatness on percussion. 
This condition is sometimes misleading. Not infrequently the signs of dis- 
tant breathing and flatness on percussion, in addition to a continuous high 
temperature, will simulate an empyema. An exploratory needle introduced 
may strike a small pocket of pus and thus an empyema may be suspected. 
These cases, if operated, frequently show nothing but the ordinary signs of 
adhesions so common at this stage of the disease. 



CEREBRAL PNEUMONIA. 



467 



The Blood in Pneumonia. 
— Baginsky maintains that the 
examination of the blood will 
show the progress of this dis- 
ease, and he believes that the 
leucocytosis so common in this 
disease has an important bear- 
ing on the prognosis of this 
condition. Felsenthal and 
Schlesinger, also Monti, Berg- 
griin, and Loos, have found 
that there is an increase of the 
polynuclear cells, whereas the 
eosinophile cells disappear. 
When the temperature returns 
to normal during the crisis in 
pneumonia, the leucocytosis 
which formerly existed also 
disappears. Thus, some au- 
thors speak of a <f blood crisis." 

The Urine.— This is fre- 
quently high-colored and very 
scanty, especially so during the 
height of the disease. It also 
has a very high specific gravity 
and frequently contains albu- 
min. Acetone can also fre- 
quently be found in the urine. 
The albumin frequently dis- 
appears after the crisis. The 
phosphates seem increased, 
though some authors maintain 
that they are decreased during 
the progress of this inflamma- 
tory type of disease. The 
diazo reaction is only found in 
that form of pneumonia which 
seems to have a typhoid tend- 
ency. Indican is very rarely 
or never found unless there is 
some form of intestinal putre- 
factive complication. 




Fig. 148. — Lobar Pneumonia of a Severe 
Type, seen by me in consultation with Dr. S» 
M. Landsmann. The effect of the poison is 
easily seen by studying the pulse-rate. Case 
Recovered. (Original.) 



468 



THE INFECTIOUS DISEASES. 



Relapse. — It is not infrequent to have one and the same area of lung 
reinvaded; thus the disease may run a second course over the same portion 
of the lung just as it did in the first attack. 

Two Instbuctive Cases of Ceeebral Pneumonia. 

Case I. — Baby E., about six months old, a nursing baby, was seen by me in 
consultation with Dr. Osias. The history was as follows: The child had been ill for 
several days, was restless and feverish, and had vomited. The stools were green- 
ish and contained a large quantity of cheesy curds, in addition to mucus. The 



DATE 


9 


io 


ii 


12 


13 


14 


15 


16 


IT 


18 


19 




CENTIGRADE 


FAHRENHEIT 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


<»' ~ 


- 8 
106 'a 






















; 




• 8 
_ • 6 

- 105' 2 


























40° — 


r il 

- I04-' t 


























39 ~ 


■ 8 

-• • s 
- 103 t 






h 


i 


















•8 
•6 

- 102' t 






V 


\ 
















38 ~" 


- -8 

- ioi : f 






f V 


j:\ 


















= 100' 2 








\ 


















— 


- .;! 

- 99-2 














\ 


F 










37 


_ • 8 






















V s 


*> • 


NORMAL 
TCMPtftATUHE.— 


- 98. 1 














\ 


: 










■ 8 
• 6 

= 21' t 












< 


\N 


■ 










36 


■ 8 

- ■ G 

- 96" 2 




























PULSE 


^ 


M 


$%£ 


$& 







$& 


^ 





o¥ 


M 


/ 


RESPIRATIONS 


^ 





0> 


&4> 


f4 


f4\ 




?* 


fi 


H 


p& 


/ 



Fig. 149. — A Case of Cerebral Pneumonia. (Original.) 



abdomen was slightly retracted, the extremities were cold; there was no oedema 
present. The child did not seem to take the breast very well and vomited fre- 
quently after nursing. The temperature was 102 4 / 5 ° F., per rectum, pulse 140, 
respiration 44. Unilateral spasms with twitchings of the muscles of the shoulder, 
arm, leg, and foot were constantly present. Twitchings of the muscles of the 
eye and a constant rolling of the eyeball were noticed; the head was thrown 
backward; the muscles of the neck were rather rigid, although there was no distinct 
opisthotonos. The spasms were confined to the right side of the body; the knee- 
jerk at the patella was absent on the right side; the plantar reflex on the right side 
was slightly present; the patellar reflex was normal on the left side and the plantar 
reflex was more distinct; the pupils responded very sluggishly and were unusually 
large; this dilatation of the pupils persisted through the whole illness, until con- 



CEREBRAL PNEUMONIA. 



4G9 



valescence was established. The examination of the thorax showed intense pul- 
monary congestion; there was slight resistance on percussion and marked dullness. 
Judging from the ratio between the pulse and the respiration, the diagnosis of 
pneumonia was hardly possible. The physical signs on auscultation showed bronchial 
breathing and a distinct crepitant rale. The diagnosis of cerebral 'pneumonia was 
made, although meningitis per se was excluded. 

The treatment was directed to relieve the pneumonic infection. Expectorants, 
in addition to inhalations of steam, were ordered. Cold compresses were used 
as antipyretics, and castor-oil or calomel was given to cleanse the gastro-intestinal 
tract. The disease progressed; the temperature increased and rose to 103 4 / 6 ° F. 



1 DATE 


z 


3 


4 


5 


6 


7 


3 


CENT3RADS 


FAHRENHEIT 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


4J 


— ■ 8 
106 't 


A 


': 














- 105° 2 


A 


'W 


w 


L 


( i 








40° — 


: :| 

- J04-* 2 


/ 


: 


V . 


fr 


\h 








39° — 


= 103 I 


\ 


: 




r* 


V 








= :% 

- 102 2 


■ 






/ : 


r 


\ 






38° "" 


- -8 

- • 6 

- loi' : t 






: 


• 




\ 






- . -8 

— ; 6 

- 100° 2 












\ 








\ 




- • 8 

- • 6 

- 99' 2 












V 


" 


37 


U • 8 














\n 



Fig. 150. — Cerebral Pneumonia with High Temperature and Marked 
Decrease in Temperature After Cold Baths. (Original.) 



on the following day, and to 1047 5 ° F. on the third and fourth days. With the 
rise of temperature the pulse-rate was increased to 140, respirations to 52. On 
the fifth day of the disease there was a marked somnolence, stupor and partial 
Coma. The head now showed a distinct opisthotonos; the sterno-cleido-mastoids 
were very rigid; the pupils were both dilated and the convulsions continued as 
before. Leeches were applied, over the mastoid portion of the temporal bone to 
relieve the cerebral congestion; the scalp was shaved and iodoform collodion, 
10 per cent., was painted on the occiput; ice-bags were applied over the whole of 
the cranium as well as to the nape of the neck; mustard foot-baths were frequently 
given and afforded some relief during the severe spasms. An enema consisting of 
chloral hydrate and sodium bromide, 5 grains each, with 1 ounce of starch water, 
was ordered. This was to be repeated every three hours until the spasms ceased. 
Before injecting the above drugs both the rectum and the colon were flushed with 
soap-water enema. 

On the seventh day of the disease there was a distinct crisis, inasmuch as the 



470 THE INFECTIOUS DISEASES.. 

temperature dropped from 104° to 97°, a drop of 7 degrees. (Fig. 154.) Stimula- 
ting expectorants were then ordered in the following manner: — 

IJ Ammon. carb 15 grains 

Syrup, pruni virgin 4 drachms 

Aqua? camph q. s. ad - 2 ounces 

M. Half a teaspoonful every two hours. 

The child's convalescence continued. The pneumonia completely subsided; reso- 
lution set in; the spasms, which had been so disagreeable and persistent, also stopped. 
The child commenced to show signs of consciousness, played, laughed, and cooed; the 
stools, which had been so greenish and curdled, assumed a more natural yellowish 
color and pasty consistency. The appetite seemed to return; the infant nursed 
better, the nights were more comfortable, and the child slept from one feeding time 
until the next. 

Case II. — Hannah T., 7 years old, was taken sick with fever, complained of 
being tired, and was very thirsty. She had anorexia and was inclined to constipation. 
She also complained of headaches. When first seen by me her temperature was 
103.4° F. in the mouth, the pulse 168, respiration 34. She had a very coated tongue; 
the throat was dry; there were no patches visible. There was no history of exposure 
to contagious diseases; a gastric catarrh was suspected. The respiration and pulse 
ratio suggested a pulmonary complication. 

The physical examination of the thorax: gave no evidence of consolidation, 
merely roughened, harsh breathing, some rhonchi and slight resistance on percussing 
the right apex anteriorly. No diagnosis except "fever" was made. I ordered 
calomel 1 grain with powdered rhubarb 3 grains. Citrate of magnesia was given 
lor the thirst. A fluid diet, consisting of equal parts of Seltzer and milk, with 
sponging of the chest with alcohol and water every hour, and cool cloths, moistened 
with evaporating lotions like bay rum or Florida water, to the forehead were also 
ordered. 

I examined a specimen of urine which contained nothing abnormal. On the) 
following morning, twelve hours after my first visit, the temperature by rectum 
was 104.4° F., pulse 172, respiration 68 while asleep. The bowels had been 
thoroughly cleaned, still there was no evidence of pneumonia, but the child seemed 
to be greatly depressed. There was marked apathy; the child was very restless and 
had not slept. Constant twitchings of the muscles of the face and extremities 
occurred; the child cried out while in the stupor, refused food, attempted to bite 
and screamed loudly. The patellar reflexes were both present, the pupils reacted 
normally, the head was not retracted nor were the muscles rigid. There was no 
opisthotonos ; the child could be roused by> loud talking, or by being touched. 
The temperature in the evening was 106.2° F. by rectum, the pulse 124, respiration 
40. One^drop doses of tincture of aconite were given every hour for eight hours 
and had no effect on the temperature, but did seem to reduce the pulse-rate and 
steady the heart's action. 

The cold pack was ordered, to be renewed every half-hour until the temperature 
dropped to 102° F. Freshly prepared spiritus mindererus, one-half teaspoonful every 
half-hour until the temperature remained at 102° F., was also ordered. Warm 
mustard foot-baths were ordered to stimulate the circulation, and whisky with milk 
(3j to §iv), whenever possible. No distinct evidences of pneumonia were obtained on 
auscultation or percussion. 

The temperature continued to rise, until 106° F. was reached. Dry cups were 
applied over 1 the posterior portion of the lungs; also an ice-cap to the head. Colon 



CEREBRAL PNEUMONIA. 471 

flushings with water at a temperature of 60° F. were also ordered, to be 
repeated every three hours. These seemed to have a very soothing effect on the 
nervous system. The child was much quieter after them and the temperature was 
gradually reduced. 

Frequently after a cool tub bath, combined with a cold pack, the temperature 
dropped three to four degrees. (Fig. 150.) Creosote carbonate, in 3-drop doses, 
was ordered every three hours, to be given in milk, soup or chocolate. This dose 
was increased gradually by the addition of one drop each day, until the child 
received ten drops every four hours. No systemic disturbance was noticed, thero 
was no discoloration of the urine and no toxic symptoms resulted from the creosote 
treatment. A decided antithermic effect without cardiac depression was noticed. 
(A convenient way of giving the creosote is to add the drops to some Tokay wine 
or to combine it with whisky and water.) The mustard foot-baths given daily 
acted as a valuable antipyretic. 

Creosote steam inhalations were also ordered. Beechwood creosote, about a 
teaspoonful to a pint of boiling water, was permitted to steam on a table several 
feet from the patient. This powerful vapor soon impregnated the air, so that the 
creosote could be smelt throughout the whole apartment. It certainly acted very 
well, not only on the temperature, but also in loosening viscid secretion. 

The vital point in the treatment consisted in giving a supporting diet of eggs 
beaten up with sugar and Tokay wine, concentrated soups, and milk predigested with 
peptonizing powder. Malt' extract was given as a restorative and also for its 
diastasic effect. The treatment was continued until the child's temperature remained 
normal for several days, when all forms of creosote were discontinued. 

It is interesting to note that very great depression of the nervous system, 
violent twitch ings of the muscles, and talking aloud while asleep continued for 
several weeks after convalescence was established. The child slept at least twenty 
hours out of the twenty-four for fully one week. It was at times difficult to arouse 
her to take nourishment. This great stupor was evidently due to the profound 
toxaemia which existed. The urine, which was frequently examined, showed an 
excess of phosphates, gave a strong diazo reaction, contained neither albumin nor 
sugar. The child was discharged after eight weeks and is in good health to-day. 

The following symptoms were the most noteworthy in the cases reported: — 

{a) Unilateral spasms, twitchings of the muscles of the shoulder and the 
arm, and of the leg and foot, were constantly present. (6) Twitchings of the 
muscles of the eye and a constant rolling of the eyeball, (c) The head was thrown 
backward. \d) The patellar reflex was absent on the affected side. (e) The 
plantar reflex was slight on the affected side. (/) Distinct evidences of pneumonia, 
bronchial breathing and marked dullness on percussion. (g) Convulsions and 
marked stupor later in the disease, (h) When the crisis appeared in the pneumonia, 
the cerebral symptoms subsided. (i) Marked nervous depression and extreme 
hyperesthesia of the body, which continued for weeks after all inflammatory symp- 
toms had subsided. 

Schlesinger, in studying this disease, noted that it existed chiefly in 
children between the third and sixth years. 

In acute apical pneumonia we usually note cerebral symptoms due to 
the irritation of the cervical ganglion. These symptoms subside with the 
crisis of pneumonia. They must not be confounded with meningitis, which 
is a distinct disease, although a frequent complication of pneumonia. 



472 THE INFECTIOUS DISEASES. 

Diagnosis. — The diagnosis of pneumonia is easy when the physical 
symptoms of dullness on percussion, bronchial breathing, moist rales, and 
bronchophony are shown. These symptoms are not always present and are 
frequently absent during the first few days of the disease. The diagnosis 
can be made by the disturbed ratio between pulse and respiration, as pre- 
viously noted. In addition thereto, the peculiar character of the respira- 
tion, added to the cough, will certainly aid in establishing the diagnosis! 
The vital point to remember is that, normally, bronchial breathing is heard 
posteriorly between the scapulae and also in the regio supraspinata dextra. 
We must also remember that dullness on percussion appears somewhat 
higher on the right side posteriorly in the lower lobe than on the left side. 
The positive diagnosis can therefore only be made by noting the physical 
signs in the lungs and excluding the symptoms pointing to a gastric catarrh, 
to a typhoid fever or a meningitis. 

Atalectasis pulmonum can easily be differentiated from pneumonia by 
the absence of fever and by the marked difference in the dullness on per- 
cussion and usually by the absence of bronchial breathing. When fever 
recurs after it has apparently terminated, some complication must be sus- 
pected. Symptoms pointing to a pleuritic effusion are dullness on percus- 
sion and diminished respiratory murmur over the affected area. Gangrene 
of the lungs can usually, be detected by the odor of the breath and the asso- 
ciated condition of collapse. If the condition assumes a chronic type and 
is associated with headache and fever^ and if the child, in addition, com- 
mences to emaciate, then we may suspect the development of tuberculosis. 
To render such diagnosis positive, some of the sputum or expectoration 
should be examined for' the presence of tubercle bacilli, the presence of 
which will establish the diagnosis. The absence of tubercle bacilli in the 
sputum does not necessarily mean that tuberculosis is absent. 

The Prognosis. — The prognosis of croupous pneumonia is relatively 
good. Out of 173 cases reported by Baginsky, of Berlin, 4 per cent. died. 
These latter children were very poorly nourished. 

Fatal cases may be expected in bottle-fed infants rather than in breast- 
fed infants. An abnormal developed thorax, so common in rickets, has an 
important bearing on the prognosis of this disease. Pigeon-breasted and 
narrow-chested infants, having an improperly developed lung space, are more 
prone to a fatal termination. 

The development of symptoms of tuberculosis or abscess of the lung, 
or the extension of a pneumonia and the continuation of the same, will mean 
a depression of the heart's action and an inhibiting of the recuperative 
tendency. The vital point will be the question of nutrition. The greater 
the amount of food taken the better will be the chance for the patient's 
recovery; thus the maxim in treating a pneumonia, "Feed the stomach,*' 
is one that I have learned to indorse and verify. 



LOBAR PNEUMONIA. 473 

Treatment. 1 — The most important symptoms to be remembered in the 
treatment of this disease are the condition of the heart, the pulse-rate, the 
respirations, the temperature, and the condition of the kidneys, to be noted 
by the quantity and the quality of the urine secreted. 

Isolate the Child. — As lobar pneumonia is an acute infectious disease 
caused by the invasion of the pneumococcus, it is transmissible. Our first 
duty is to isolate. A case of pneumonia should be isolated as strictly as a 
case of diphtheria. All healthy persons should be excluded, be they friends 
or family. It is best to let them know that this disease can be disseminated. 

In the treatment of pneumonia we must remember that toxaemia and 
high temperature will produce degeneration of the muscular fiber of the 
heart, which, if prolonged, will result in heart-failure. Hence our treat- 
ment must be directed to lowering the temperature and to control the 
inflammatory process before stagnation of the blood and hepatization have 
taken place, thus aiming to retain the integrity of the respiratory tract. 

Any interference with the proper action of the respiratory apparatus 
leads to overloading and ultimate failure of the right side of the heart. 
Hence we must seek to keep up the respiratory pump by lessening the fre- 
quency and increasing the depth of the respirations. 

A great many cases will get well without treatment. This is called the 
"self -limited" condition. The disease simply runs its course, and if the 
patient is properly fed, strengthened, and guarded, a favorable termination 
may be expected. On the other hand, there are certain symptoms which 
demand treatment. For example, hyperpyrexia will require treatment, espe- 
cially so as the continuation of the same may be the means of developing 
disturbances resulting in convulsions. My preference has always been for 
the use of cold externally. If cyanosis .exists then warm flaxseed poultices 
may be tried. 

The sudden application of cold externally causes a deep inspiration and 
consequent forcing of air through the alveoli, thus preventing atelectasis. 
The air surrounding the child should be kept moist with steam from a tea- 
kettle having a long spout directed toward the child (Fig. 134). 

The following case was attended by me in the babies' ward of the New 
York Post-Graduate Hospital: — 

Child F. A., 5 years old. My attention was called on August 12th to a tem- 
perature of 99V B ° F., which rose to 104 3 / 5 ° F., by 8.30 the following evening. Per- 
cussion showed dullness over a complete lobe of the left lung, bronchial breathing, 
cough, no expectoration. The respiration rose from 36 in the morning to 50 
in the evening, and the pulse from 120 to 130 per minute. Until the diagnosis 
was positive the child was put on the expectant plan of treatment. The 
temperature rose to 105° F. on the second day, in spite of sponge baths con- 
sisting of equal parts of alcohol and water. After a few hours the temperature 
rose to its former height, sometimes going beyond that, prior to the sponge bath. 



1 For vaccine treatment, see "Bacterial Vaccines." 



474 THE INFECTIOUS DISEASES. 

In order then to have a more lasting effect, it was deemed necessary to give 
the tub baths, that is, to immerse the child from the neck to the feet in water of 
about 90° F. and then add ice until the temperature of the bath is 70° F. The 
child was kept in the bath from two to five minutes. 

The first tub bath brought the temperature from 10475° F. to 100° F. This 
drop lasted about two hours. The temperature did not rise more than two degrees 
until the following afternoon at 4 p.m., when it reached 104 4 /5° F. This is a natural 
course in a severe pneumonia. The second tub bath had the effect of lowering the 
temperature from 104 4 / B ° F. to 1017 5 ° F., a decrease of 3 8 / B ° F. in one nour. 

On the 19th of August, the eighth day of the disease, the temperature reached 
1047 5 ° F. at 6 p.m. A tub bath given brought the temperature to 103° F. at 7 p.m., 
a fall of 17 5 °'F. in one hour. This same temperature continued until 9 p.m., after 
which it began to fall, reaching normal on the following day, the ninth day of 
disease. The boy was discharged cured. He was entirely well when I last heard of 
him. 

In the above case true symptomatic treatment was carried out. The severe 
cough received an expectorant with an anodyne (codeine) when necessary to relieve 
pain. Bowels and bladder were carefully watched. Stimulants given when required 
— no antipyretics. Diluted milk and whey, every three hours. Cool water when- 
ever thirsty. 

Drug Treatment. — When high fever persists in a weakened child with 
?ery low resisting power, snch fever must be reduced. The child's system 
must be carefully watched while fever is in progress. One child will tol- 
erate a temperature of 105° F., laugh and play, and take its food regularly, 
while another child in a similar pulmonary condition will show extensive 
cerebral irritation, somnolence, tremor, twitching of the muscles, and pos- 
sibly convulsions at a temperature of 103° or 104° F. In the latter instance 
it shows that the poison from the pneumococcus infection has overwhelmed 
the nerve centers governing heat production, and in such instances, when 
decided nervous or cerebral symptoms present themselves, "a reduction of 
temperature is demanded," or we must not be surprised to see convulsions 
set in, with probably a fatal termination. 

How Shall We Reduce the Temperature in Children?— When we con- 
sider that antipyretic drugs depress the nerve centers governing heat pro- 
duction and increase the work of the emunctories, already loaded down by 
poison brought to them for elimination, it can be seen that their use is 
contraindicated. Those who believe in phagocytosis may be reminded that 
antipyretics arrest the development of leucocytosis, and thus remove one of 
the means of destroying the germs of the disease, according to one theory, 
or the antitoxin generated or developed, according to another (Hob art A. 
Hare) . 

Jacubowitsch and Muller and many others have proved conclusively 
that antipyrine decreases the elimination of urea by the urine. It also 
decreases the urinary flow, which is a very harmful effect, when we con- 
eider the great importance of eliminating effete matter from the body. 



LOBAR PNEUMONIA. 475 

That antipyretics depress the heart's action is only too well known; there- 
fore, rather than to combine them with musk, camphor, or other cardiac 
stimulants, I have discarded them. 

Lactophenin, antipyrine, phenacetin, salol, salipyrine, and quinine are 
among the more common antipyretic measures used as indicated, but, as they 
are cardiac depressants, must be cautiously prescribed. The tincture of 
aconite, in 1-minim doses, repeated every hour, has a remarkably good effect 
on this disease. In addition thereto, spirits of mindererus in half-teaspoonf ul 
doses, repeated every hour, will have a very good diaphoretic effect. Dover's 
powder will relieve cough and will also aid diaphoresis. 

For difficult breathing nothing will serve as well as local depletion. 
For this purpose the application of dry cups over the affected areas of the 
lung will afford in some instances immediate relief. Dry cupping may 
be repeated every hour in severe dyspnoea if necessary. Tincture of iodine 
applied locally over the area of the lung affected will also be advantageous 
in some instances. If the pain is severe in pleuro-pneumonia, strapping the 
chest with strips of adhesive plaster will support the ribs and relieve the 
cough. 

If convulsions persist an ice-bag applied over the head and also at the 
nape of the neck will be very valuable. 

I frequently use one or two leeches applied over the mastoid process 
of the temporal bone and permit very free bleeding. This is especially 
indicated when there is intense engorgement of the brain with marked 
stupor and coma. We can frequently relieve congestion by the application 
of leeches to the alae nasi. A simple but most effective remedy is the use 
of mustard foot-baths frequently given. 

To relieve the cerebral hypersemia, calomel in 1 / 10 -grain doses, and 
increased, may be repeated until liquid stools have been produced. It is 
one of our most valuable remedies and should be used at the onset of a 
suspected pneumonia. Attention to the stomach and bowels will frequently 
be the means of saving the life of the patient. I insist upon a loose con- 
dition of the bowels, and if the same cannot be produced by the admin- 
istration of calomel, then an enema should be given by flushing the colon 
as often as once in twelve hours to cleanse the parts. When children are 
old enough, then one of the most valuable remedies is to give copious drinks 
of citrate of magnesia. This will not only quench the thirst, but will act 
as a laxative, and in addition thereto stimulate the secretion of urine. 
We find, therefore, that the emunctories require especial stimulation and 
attention during the course of lobar pneumonia. 

In no disease is strychnine more valuable than during the course 
of pneumonia. Very small doses of only 1 / 200 or 1 / 100 grain, repeated 
every hour, may be given without fear during the progress of this dis- 
ease. The question of stimulation is one of individuality. Each case 



476 THE INFECTIOUS DISEASES. 

must be treated on its own merits and the individual condition studied. 
When the heart's action is feeble and the pulse is thready, whisky must 
be given. In some cases five to thirty drops of good whisky may be 
given as often as every half-hour until the pulse responds to the stim- 
ulant. I frequently combine strychnine with whisky. In other cases 
champagne in half-drachm or drachm doses will be found far more 
effectual. Some children object to the taste of whisky or champagne, but 
will take a sweetened wine. In such cases give good, old Tokay in half- 
drachm doses as often as is required. When there is an aversion to the 
taking of medicine or if the child rebels against stimulation by the mouth 
and it is urgently called for, then half a teacupful of hot water, temperature 
of 100° F. to 105° F., to which a teaspoonful of either whisky or alcohol is 
added, may be thrown into the colon by means of a colon tube. When inani- 
tion exists, as in the septic type of pneumonia, the Murphy drip, using nor- 
mal saline solution, is indicated. Hypodermic medication must not be 
overlooked, and frequently it is wise to use whisky, ether, or spirits of cam- 
phor. A valuable method of giving camphor hypodermically is by inject- 
ing camphorated oil, from 5 to 15 minims. Musk is one of our best cardiac 
stimulants, and if the pulse-rate is feeble it may be given in 1- to 5- drop 
doses, repeated in three or four hours, if necessary. 

Hygienic Treatment: Room Temperature. — One of the most impor- 
tant factors is the regulation of the temperature of the room. Every child 
having a pneumonia should be put into a room having a temperature of 65° 
to 70° F. An equable temperature should be maintained, as the same is 
very grateful during the febrile stage of this disease. Fresh air should al- 
ways be admitted. 

Oxygen. — When severe dyspnoea occurs and if cyanosis exists, then 
oxygen inhalations may be required. Under these conditions several res- 
pirations should be given every few minutes until the lips lose their cyanotic 
appearance and again have their natural color. 

Sponge Baths. — The surface of the body should be sponged with tepid 
water every day. Equal parts of alcohol and water are grateful to the 
patient, and should be used every hour if the temperature requires it. If, 
however, the temperature is not high, then a sponge bath to which a little 
alcohol has been added will be grateful, and may be given every morning 
and evening. 

Another valuable means of reducing the temperature is by sponging 
every hour with acetic ether. This must be cautiously used, owing to its 
volatile and inflammable tendencies. 

The Oil-silk Jacket. — This jacket is valuable when we desire a dia- 
phoretic effect. It also prevents the chilling of the surface of the lung by 
maintaining a uniform temperature. The details of making this jacket 
can be found in the article on "Broncho-pneumonia," page 434. 



TUBERCULOUS PNEUMONIA. 477 

Dietetic Treatment. — As previously stated, the prognosis in this con- 
dition depends on the amount of food the patient will take. A milk diet 
should be prescribed. Buttermilk, kumyss, zoolak, rice and milk, farina 
and milk, oatmeal and milk, and cold foods, such as cornstarch pudding, 
rice pudding, and tapioca pudding, are very grateful. If the child is very 
thirsty and is over 2 years old, ice cream may be permitted very sparingly. 
This is very grateful to the little patient, and if made from fresh cream is 
very nutritious. Concentrated soups, chicken broth, and veal broth may 
be permitted. So also calf s foot jelly, chicken jelly, albumin in the form 
of raw white of egg, to which some sugar is added, may be given. A soft- 
boiled egg or raw yolk of egg with sugar may also be given. 

The interval between each feeding must be prolonged, owing to the 
subnormal condition of the digestive tract. If children are fed from 
the bottle, or if they are nursing babies, then they should be fed with a 
longer interval than previous to the time of this illness; for example, if 
the infant has been given the breast every three hours, it is a good rule to 
extend the nursing time to three and one-half or four hours, if it is pos- 
sible. In this manner we "will not only aid in the assimilation of the food, 
but frequently prevent stagnation of milk which had been previously taken. 

Night Feeding. — The rule which governs the feeding of healthy chil- 
dren cannot be applied to children suffering with pneumonia. During the 
febrile stage large quantities of liquids are demanded. In order to overcome 
the cardiac depression good nourishment is indicated. A nursling suffering 
with pneumonia should be given the breast several times during the night. 
Bottle-fed infants may also receive some nutrition every three or four hours 
during the night. A favorable termination in this disease can only be 
expected when the depressed vitality is stimulated by nutrition. 

Tuberculous Pneumonia. 

There are four pathological conditions which illustrate the various 
stages of the disease; they are: first, a bronchitis with rhonchi scattered 
through the chest ; second, small areas of consolidation or partial consolida- 
tion; third, complete consolidation with bronchial breathing, dull areas 
on percussion; fourth, excavation with cavernous or amphoric breathing. 

In its early stages the disease resembles broncho-pneumonia. 

Cavities are frequently found post-mortem. They are difficult to find 
in children under 3 years of age. On the other hand, children over 8 or 9 
years have cavities which can be recognized as early as in the adult. 

Holt states that "the reason why in infancy cavities are so seldom recog- 
nized during life, is because they are generally small, often centrally located, 
nearly always filled with thick pus or cheesy matter, and rarely communicate 
freely with the bronchi. On the other hand, it is very common to find 



478 THE INFECTIOUS DISEASES. 

signs in young children which, if heard in adults, would be regarded as 
almost positive evidence of a cavity although none is present. These 
signs are cracked-pot resonance and cavernous breathing. They are not 
usually due to bronchiectasis, since this condition belongs to chronic cases, 
and especially to older children, but most frequently to consolidation about 
a large bronchus superficially situated, viz. : below the clavicle, high in the 
axilla, and in the interscapular region. The wide area over which this 
broncho-cavernous breathing is heard is one of the most striking points of 
difference from the signs of a cavity." 

Course. — There are two types of cases: First, rapid cases or those 
terminating very quickly; second, those assuming a chronic course (pro- 
tracted cases). 

1. The Rapid Type. — The pathological process is a bronchitis affecting 
the smaller tubes surrounded by areas of consolidation. These lesions are 
the same as are found in broncho-pneumonia. The temperature curve is fre- 
quently the same as found in broncho-pneumonia, ranging between 100° and 
104° F. The areas of consolidation are more frequently found in the upper 
lobes. There is also broncho-vesicular breathing and bronchophony. Per- 
cussion note shows slight dullness. The cough may assume a paroxysmal 
character similar to whooping-cough. Convulsions and frequently menin- 
geal symptoms, such as a slowness of the pulse or Cheyne-Stokes breathing, 
will show the extension of the disease to the brain. 

2. Those Assuming a Chronic or Protracted Course. — The duration 
of .this form of the disease may be between one and six months. Some cases 
may last but three months. This is the most common type of the disease 
seen. Cases are frequently seen following measles, whooping-cough, pneu- 
monia, or diphtheria. Those cases I have seen ended fatally within three or 
four months. There is usually a slight improvement after the second or 
third week of this disease. The temperature falls and the physical signs 
seem to disappear. As a rule the disease reappears with more violent symp- 
toms, and emaciation, fever, and sweating continue until the end. The 
temperature curve is,not regular. In some cases it ranges between 99° and 
101° F. Other cases will have a much higher temperature, the thermometer 
registering 104° F. frequently. Expectoration is rarely seen in young 
infants, as they invariably cough and swallow the same. The breathing 
is usually labored; hence dyspnoea is almost always present. When we 
have Cheyne-Stokes breathing, or irregular breathing, with a slow pulse, 
then cerebral complication should be suspected. 



CHAPTEE IV. 

CHRONIC PULMONARY TUBERCULOSIS (TUBERCULOUS 
BRONCHO-PNEUMONIA) . 

This condition is rarely found in infants and very young children. 
When chronic pulmonary tuberculosis is noted it is usually seen in children 
after the sixth or eighth year. 



DATE 






m|e 


m|e 


m|e|m|e 


Mir 


m|f 


m|e 


nr 


m|e ImIe 


Mir 


nJt 


m|e 


If 


F 


rilE 


wk 


g c 




106 
108 


B 
















— 














^ 








101 
100 


I 














H 
























HI 


Hi 














m 








es 






1 9 






















































= 
































E> 














Pulse 








1 


















































Resp. 


























































d»tof 


8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 



Fig. 151. — Fever curve during the early period of Chronic Pulmonary 
Tuberculosis. The daily excursions are slight, and generally range between 
102° and 104° F. (Original.) 




Fig. 152, — Temperature curve during the fifth month, when the disease 
is more extended and softening has taken place with the formation of cavi- 
ties. The temperature is more hectic in character. The morning tempera- 
ture may be normal or subnormal, while the evening temperature ranges 
between 103° and 105° F. (Original.) 

Pathology. — Osier states that small cavities are by no means rare in 
chronic pulmonary tuberculosis of children, but very large excavations are 
rare; thus in 265 cases noted by Barthez and Sanne there were 77 cases 

(479) 



480 



THE INFECTIOUS DISEASES. 



with excavation, chiefly in the upper lobes. In the analysis by Leroux of 
the cases of the late Parrot, in 219 children under 2 years of age, 
there were 57 instances in which cavities existed. In five of these the 
children were under three months. In long-standing cases hard, firm, 
fibrous tubercles are found, and sometimes cutaneous nodules. The pri- 




Fig. 153. — Chronic Nodular Tuberculous Broncho-pneumonia, (a, b, 
c, d) tuberculous foci of variable size and shape, corresponding to the in- 
filtrated alveolar system; (e) transverse section through an infiltrated 
occluded bronchiole; {f) small arterial branch; (g) group of nodules under- 
going coalescence; (h) small unaltered bronchus; (k) artery. X 6. 
(Ziegler.) 



mary lesion in a great majority of instances is a tuberculous broncho- 
pneumonia, taking its origin in the smaller bronchioles, leading to peri- 
bronchial nodules and subsequent peribronchial alveolitis. The lesions are 
similar to those met with in tuberculosis of adults — miliary tubercles, 
peribronchial nodules, caseous blocks, areas of softening and of fibroid 
induration, and cavities of various sizes. We do not see so frequently the 



PULMONARY TUBERCULOSIS. 481 

invasion of the lung from the apex downward. The chief seat of disease 
may be in the central portion of the lung, or even at the base. In tuber- 
culosis of the lymph glands the groups along the trachea and about the 
bronchi may be greatly enlarged and caseous, forming on section a very 
striking feature in the chronic pulmonary tuberculosis of children. 

Symptoms. — Chronic pulmonary tuberculosis in the child presents the 
same symptoms as in the adult. Usually a broncho-pneumonia will first be 
encountered, or the symptoms present will resemble those of a broncho- 
pneumonia. When fever persists and there are evidences of a general 
breakdown, such as malaise, loss of appetite, and emaciation with or with- 
out cough, then this condition must be suspected. When these children 
expectorate, the same resembles that seen in adults. Tubercle bacilli have 
frequently been found in the expectoration of cases under my care. Blood 
spitting in which the mucus is blood-stained has been seen by me. The 
blood is bright red in color. Epistaxis is sometimes seen during the course 
of the disease. The temperature ranges between 100° and 102° F. in the 
beginning of the disease ; later on it assumes the real hectic character ; 
thus, the temperature may be 99° to 100° F. in the morning, and 103° to 
105° F. in the evening. 

Pleuritic pains are complained of in various parts of the chest. There 
is marked dyspnoea and frequently cyanosis. Osier states that some cases 
do not have any pain throughout the course of the disease. A general 
emaciation associated with muscular weakness and anaemia is usually seen 
later in the disease. Tubercular ulceration of the intestine will frequently 
cause diarrhoea. In a child seen by me with chronic tuberculosis of the 
lungs, a general anasarca was present. 

Katie B., 8 years old, has been a very delicate child. She was breast- and 
bottle- fed, and lived in a tenement house. 

Family History. — The father was a drunkard and did not support his family; 
the mother is a frail, anaemic woman, although no evidence of pulmonary disease 
could be found. The child was late in walking, late in teething, and late in talking. 
Distinct evidence of rickets of the bones was everywhere noted. When 4 years 
old the child had measles, complicated with broncho-pneumonia, after which a 
cough remained. Three months after the measles the child still coughed and 
showed evidences of malnutrition. The cough persisted in spite of codliver-oil, 
malt extract, and iron, which were liberally given. As the family was poor, 
they could not take the child to the country for a complete change of air. I did 
not see the case again for two years, when I saw it through the courtesy of Dr. 
John H. Wurthman. At this time she had a cavity at the apex of the right lung, was 
terribly emaciated, and complained of pain on breathing and suffered with marked 
dyspnoea. Pleuritic friction sounds were heard over small areas of the chest on 
both sides. The child had haemoptysis, besides a purulent expectoration. Tubercle 
bacilli were found in the sputum. She died after a violent haemorrhage, from 
exhaustion and heart-failure. 

The treatment is the same as described for acute tuberculosis. 

31 



482 TH E INFECTIOUS DISEASES. 



Pulmonary Gangrene. 



This condition, fortunately, is very rare. 

Diagnosis. — This is made by the characteristic foul odor of the breath 
and the expectorated gangrenous material. I have seen a case of this kind 
during my summer service at the Willard Parker Hospital in a child that 
suffered with laryngeal diphtheria complicated by broncho-pneumonia. The 
septic condition dragged on for weeks. There was a very putrid odor to 
the breath. The child finally died of sepsis. As a rule the diagnosis can 
only be made post-mortem. 

Treatment. — Kestorative treatment, consisting of light, nutritious diet, 
should be given and stimulants liberally used. Steam inhalations impreg- 
nated with beechwood creosote will modify the odor. Creosote carbonate 
can be given with the food in 5- to 10- minim doses, several times a day. 



CHAPTER V. 
ACUTE TUBEECULOSIS (MILIARY TUBERCULOSIS). 1 

Tubekculosis is a specific infectious disease caused by invasion of the 
tubercle bacillus. The disease is 'disseminated by the same. 

Etiology. — Acute miliary tuberculosis is frequently seen in very young 
children. I have seen cases in bottle-fed infants under 1 year of age. It 
is also frequently associated with tubercular meningitis. As a rule it fol- 
lows those diseases which devitalize the system, such as the acute infec- 
tious diseases. In prolonged diseases affecting the air passages, tubercu- 
losis frequently follows. 

Cows' Milk. — The majority of cases of tuberculosis are found in chil- 
dren brought up by artificial feeding. This implies that such children 
received cows' milk. The dangers of infection by or wifh the tubercle 
bacillus can usually be excluded inasmuch as nearly every woman boils the 
milk. The more modern woman of to-day, instead of boiling cows' milk, 
submits the food to a steaming process, either by using a sterilizer or a 
pasteurizer. The result is the same, namely, the destruction of pathogenic 
bacteria of all kind, including the tubercle bacillus. Such artificial feeding 
with cows' milk frequently results in gastro-intestinal derangement. Dys- 
peptic attacks rob the system of food required for the nutrition of bone, 
muscle and other organic structures. When such conditions persist then 
poor foundations are formed, resulting in rickets or marasmus. The tuber- 
cle bacillus easily gains entrance where subnormal conditions prevail, and 
secures a foothold that ultimately develops tuberculosis. 

Woman's Milk. — Human milk is intended by nature for the nutrition 
of infants. It offers decided 'prophylactic substances to the nurslings, for 
example: the nursing infant is very rarely afflicted with diphtheria or 
similar infectious diseases. This is most probably due to the immunity 
conferred by human serum and the antibodies or bacteriolysins which the 
serum contains during the nursing period. This also accounts for the 
rarity of pulmonary tuberculosis in children reared on woman's milk. The 
value of human milk has frequently been noted by me while studying this 
question in a children's clinic patronized by people living in the most con- 
gested district of New York City. 

The statistics of my cases of tuberculosis from the children's service 
of the German Poliklinik in New York City are very interesting. Five 
thousand children were examined at random for the presence of tubercular 



1 Tuberculosis of the bones, joints, and glands are described under separate 
articles. 

(483) 



484 TH E INFECTIOUS DISEASES. 

lesions. More than 4900 cases out of this number showed no sign of pul- 
monary disease; 1700 of these cases suffered with adenoids, pharyngeal 
disease, catarrh of the naso-pharyngeal tract, or infectious conditions due 
to poor ventilation and general unsanitary surroundings. The cases were 
taken in children from the first to the tenth year inclusive; 59 cases out 
of this whole number showed distinct evidence of pulmonary tuberculosis. 
Only 9 cases of this whole number showed the presence of tubercle 
bacilli in the sputum. The difficulty in procuring sputum was an obstacle 
in making more frequent examinations. Forty-three cases of this number 
had bone and joint tuberculosis in addition to evidences in the lungs. In 
two cases tubercular empyema was found. Five of these 59 cases had 
Pott's disease. 

TATvr.re No. 43. — Table showing Manner of Feeding in 59 Consecutive Cases of 
Tuberculosis, among the Poor. 
Manner of Feeding. Number of Cases. 

Breast milk (human milk) . » , 2 

Cows' milk 37 

Condensed milk 18 

Modified milk ( laboratory ) •. 2 

Tuberculosis in children is so closely allied to scrofulosis that a great 
many authors believe them to be identical. There certainly are a great 
many characteristics common to both. On the other hand a close scrutiny 
of the pathology of the disease will show them to be distinctly separate. 
That scrofulosis will frequently be the medium through which, later on, 
tuberculosis develops, is well known and recognized. 

"In the tuberculosis of the new-born evidence shows that the maternal 
ovum may be infected from the mother, or by the paternal seminal fluid; 
later the embryo may be infected by the placental route or amniotic fluid 
when the mother is tubercular. These modes of infection, while theoretic- 
ally possible and occasionally actually authenticated, are nevertheless ex- 
tremely infrequent in practice. By whichever of the above-mentioned routes 
the bacillus has gained entrance to the fcetal organism, there is no doubt 
that it may invade it and remain latent therein for an indefinite period. 
Unless the bacilli are actually found within the tissues, it is ex- 
tremely difficult to uphold the view that the infection has not been acquired 
after birth." 

The influence of raw meat on the evolution of experimental tubercu- 
losis has been described by Chantemesse and Cornil. 

Eichet and Hericourt published experiments showing the beneficial 
effects of raw meat in tuberculosis of dogs. Their observations were 
open to the objection that the quantity of meat given was not measured, 
and that the good effect obtained might have been due merely to the fact 



TUBERCULOSIS. 435 

that the dogs preferred larger quantities of raw meat than they would 
have eaten of boiled. To exclude this influence the following experiments 
were made. Six couples of dogs, each of the same weight and appearance, 
were taken. One of each couple was fed with boiled meat to satiety, the 
other was given an equivalent quantity of raw meat. Both were inoculated 
in the vein of the leg with tuberculosis. The dogs fed with boiled meat 
died at intervals varying from three weeks to four months. The necropsies 
showed general tuberculosis, more or less voluminous caseous granulations, 
aud advanced fatty degeneration of the liver. Those fed on raw meat were 
killed at the same time. They were all plump ; they showed less numerous 
tubercles than did the others, and less voluminous and less caseous granu- 
lations. In another experiment a dog was inoculated with tuberculosis and 
given 750 grams daily of raw meat. He preserved his strength, weight, and 
healthy appearance. He was killed at the end of twelve months. The 
necropsies showed a small number of tubercles in the viscera and tuber- 
cular interstitial nephritis. He was on the way to recovery. Two monkeys 
were inoculated with tuberculosis. One was fed on the ordinary diet, and 
died at the end of 23 days of general tuberculosis; the other was fed on raw 
meat for 15 days before the innoculation, and lived for 49 days.; 
Chantemesse and Cornil therefore conclude that the utility of raw meat 
diet in tuberculosis consisted not in overfeeding, but in the anti-tuberculous 
quality of the diet. 

The transmissibility of tuberculosis by means of drinking milk from 
cows whose udders are tuberculous, is admitted by a great many authors. 

Behring believes that milk infection remains latent for years and then 
develops tuberculosis. This he states accounts for the absence of the dis- 
ease in very young infants. 

Koch is authority for the statement that "bovine tuberculosis is an 
entirely different disease from human tuberculosis, and cannot be trans- 
mitted from a cow to a human being/' 

Westenhoeffer believes that caries of the teeth and inflamed gums, as 
seen during dentition, permit the invasion of the tubercle bacillus into 
the lymph channels of the neck, resulting in cervical, bronchial, retrosternal, 
tracheo-bronchial, and finally mesenteric tuberculosis. 1 

Chiari, of Vienna, and Freudenthal, of ~New York, believe that the 
retropharynx which harbors adenoids is the point of entrance of the tubercle 
infection. This view has alivays been held by me, inasmuch as tubercular 
meningitis results most probably from an extension upward from the 
pharynx, and downward, the infection enters through the cervical glands. 

Contact of the delicate, perhaps abraded, skin or mucous membrane 



Berlin Klin. Woch., February 15, 1904. 



486 THE INFECTIOUS DISEASES. 

of the young infant with tuberculous sputum may result in inoculation, as 
has been repeatedly shown in connection with ritual circumcision. 

The interesting observations of Lehmann show that sucking the wound 
after the ritual circumcision of Jewish children has caused tuberculosis. 
Baginsky reports a case of the transmission of tuberculosis to the eyebrow 
of a child by a tuberculous person. That tuberculosis may be transmitted 
by the process of vaccination on the arm cannot be disputed. 

There must be a certain disposition or predisposition to the develop- 
ment of this disease. Other factors which are prominent in this connec- 
tion are poor hygienic apartments; rooms in which sunshine is absent and 
in which foul air stagnates will certainly lower the normal resisting power 
of any and all individuals. When a child has passed through an acute 
infectious disease which has already lowered its vitality, then an infection 
with tuberculosis is more easily accomplished. Among such diseases which 
predispose to the development of tuberculosis are whooping-cough and 
measles. The same is also true in exhaustive diseases which drain the 
vitality of children for a long time, as, for example, after a prolonged 
attack of summer complaint. The disease frequently accompanies the 
nursing period, hence even the youngest child may become infected. 

Tuberculosis has so great a tendency to generalize itself in children 
that the question of the primary infection is not to be settled by the mere 
frequency of the lesions. The fact that children swallow their sputa is to 
be kept in mind. There is no question as to its infectiousness, while that 
of infected milk in the human species has not been absolutely demonstrated. 
Still's statistics show that in 25 cases taken consecutively, of 
children under 3 years, who did not expectorate, intestinal lesions were 
found in 19, while in a similar series, aged between 3 and 12, they were 
found in only 10. It would thus appear that autoinfection by the sputa in 
infants is a matter of serious importance. 

Bacteriology. — The germ can be traced to the blood and also the cells 
of the blood-vessels. This has been proven through studies made by Dou- 
trelepont, Lustig, Meisels, and Weigert. 

Demme found this specific germ in pus exuding from an eczema; the 
same is true about pus in otitis. Tuberculous affections of the tongue, of 
the nasal mucous membrane, of the thorax and tuberculous swellings on 
the lips of young girls have been described by Volkmann. Primary tuber- 
culosis of the thymus, of the heart, and of the vaginal mucous membrane 
have been published by Demme. A. Baginsky has described a series of 
cases of tuberculous perityphlitis, peritonitis, and enteritis. Tuberculosis 
of the testicles in children has been seen and observed by him. The so- 
called scrofulous inflammatory conditions of the joints and suppurative dis- 
eases of the bones, while being described as "scrofulous," are usually of a 
tuberculous nature. The internal organs suffer from the invasion of the 



TUBERCULOSIS. 



487 



tubercle bacillus in this connection. The lungs and the pleura, the peri- 
cardium and myocardium, the liver, spleen, and kidneys, the coverings of 
the brain, and the brain itself are. frequently affected. 

The question of the transmission of the tubercle bacillus is one that 
is still debatable. Thus Jani reports in Virchow's Archiv, Bd. 103, p. 522, 
that the seminal fluid of tuberculous persons contains tubercle bacilli. The 
cases of tubercles in the foetus are described by Johne and Armanni. 1 Bang, 
Lehmann, Birch Hirschfelcl, Eindfleisch, and Kossel are among those who 
have reported isolated cases of tuberculosis directly transmitted from 
parent to child. Hochsinger recently reported 3 cases which he describes 
as congenital tuberculosis. These cases were associated with syphilis, and 
he believes that this disease is far more frequently transmitted than is gen- 
erally recognized. Thus it appears from the studies of Brandenberg, Lesage, 




Fig. 154. — Tubercle Bacilli and Micrococcus Tetragenus (sputum). 
Gabbet's stain, Leitz ocular I, oil immersion 1 / 12 . (a) tubercle bacilli; (b) 
micrococcus tetragenus. ( Lenhartz-Brooks ) . 

and Wolff that the placenta is an exceedingly valuable culture medium for 
this specific micro-organism, and thus they account for the com- 
parative freedom of the foetus born to a tuberculous mother. 

Cornet and, more recently, Fliigge made extensive investigations show- 
ing the means of dissemination of the tubercle bacillus. We are indebted 
to them for our knowledge regarding the danger of sputum of a phthisical 
patient, and also regarding the manner of transmission of this disease. 

How susceptible very young children are can be shown by a case pub- 
lished by Wassermann, 2 in which he reports the transmission of tubercu- 
losis to a child six weeks old by being in contact in the same room with a 



1 Tenth. International Medical Congress, Bd. 5. 

2 Zeitschrift f. Hygiene^ .p. 353. 



488 THE INFECTIOUS DISEASES. 

phthisical patient for eight clays. Kitasato 1 reports the fact that tubercle 
bacilli die rapidly in the sputum, and he therefore does not believe the 
danger of the transmissibility of tuberculosis is as great as has been claimed. 
That contact with tuberculous patients is a very serious matter can be seen 
by a study of the literature. 

Mother's milk has been closely studied and the possibility of infection 
through this channel cannot be denied. 

Pathological Anatomy. — We are indebted to Bayle, Buhl, Laennec, and 
Virchow for the division and study of the pathological anatomy of this 
disease. These authors divide the conditions into two distinct parts : First, 
cheesy pneumonia ; second, the real miliary tuberculosis. By the cheesy 
pneumonia is meant that form of a chronic destructive process ending in 
cheesy necrobiosis. By the miliary tuberculosis is meant that form of dis- 
ease commencing as a tiny nodular swelling, which starts in the connective 
tissue and is associated with the lymph bodies, having a tendency to form 
broken-down cheesy masses. The pathology of this disease can certainly be 
associated with no greater name than that of Virchow, to whom we are in- 
debted for the bulk of our knowledge of this disease. 

The tubercle is a small, grayish-white, translucent, sometimes yellowish 
body. The greatest masses consist of small, round cells about the size of 
a red blood-corpuscle, and large cells resembling epithelium. There are 
also giant cells. The giant cell, as a rule, can be found in the middle of 
these tubercles and is so closely identified with this condition that it has 
been looked upon as characteristic of this disease. 

The growth of the tubercle consists in the development of new masses 
arising from the giant cells. In these giant cells there are no blood-vessels, 
and as there is no nutrition they easily break down and form what is later 
on the beginning of cheesy masses, which, by absorption and a melting 
process, are the real beginnings of cavities. At times these masses result in 
chalk deposits. The question of the specific origin of the disease has been 
finally settled by the investigations of Koch, who proved the specific micro- 
organism known as the tubercle bacillus to be the pathological factor. 

Biedert found 16 cases of primary intestinal tuberculosis among 3104 
post-mortems. 

Heller found 7.4 per cent, of primary tuberculosis among 714 post- 
mortems in diphtheria, and a total of 19.6 per cent, of all varieties of 
tuberculosis among these 714 cases. 

Orth states that primary intestinal tuberculosis is exceedingly rare in 
Berlin because of the universal use of sterilized or boiled milk. 2 



1 Zeitschr. f. Hygiene, Bd. 9, 1892, Heft 3. 

2 1 have collected and described a series of important observations on the 
association of cows' milk with tuberculosis. The pathology of the cow's udder and 
the milk ducts are also described. (See chapter on "Cows' Milk.") 



TUBERCULOSIS. 



489 





Fig. 155. — Tuberculosis. Horizontal 
section through the tuberculous lower lobe 
of the right lung of a two-year-old child. 
(a) caseous focus in the region of the an- 
terior border; (b) nontuberculous poster- 
ior border; (c) transverse section of bron- 
chus; (djd 1 ) caseated lymph glands; (e) 
pulmonary vein ; (f) point of adhesion of 
the vein e with the lymph gland d 1 ; (g) 
tubercle in the lymph vessels of the 
lung parenchyma; (h) periarterial; (i) 
peribronchial; (Tc) perivenous tubercles; (I J lymph vessel tubercles of the 
pleura; (m) tubercle in its connective tissue of the hilus of the lung. X3. 
(Ziegler.) 



490 



THE INFECTIOUS DISEASES. 



Baginsky reports that he found 8 cases of tuberculosis that died among 
871 nurslings at his Berlin hospital. These were all under ten months of 
age. On the other hand he found, among 266 children in the second year, 
13 died of miliary tuberculosis. One hundred and eighty-two children out 
of 611 died of miliary tuberculosis between the age of 2 and 4 years. Out 
of 152 children examined between the age of 4 and 6 years, 6 had miliary 
tuberculosis. 




Fig. 156.^-Acute Pulmonary Miliary Tuberculosis (Cut Surface of the 
Lung.) (a) so-called obsolete tubercle (old encapsulated caseous focus), (b) 
induration, (c) caseous, partly agminated nodules (transverse section of 
caseous bronchi.) (d) submiliary noncaseated tubercle in the true lung 
tissue, (e) tubercle of the pulmonary pleura. One half natural size. (Lang- 
erhans.) 



Still 1 considers these facts and offers some interesting .statistics, based, 
not on clinical observation, but on post-mortem findings, for the solution 
of this problem. In 769 autopsies of children, tubercle was found in 269, 
or 35.2 per cent. Tuberculosis was the actual cause of deaths in 252, or 32.8 
per cent. From these statistics, therefore, it can be roughly estimated that 



1 Clinical Journal, London. 



PLATE XVII 




Disseminated pulmonary tuberculosis with collapsed right lung and a natural 
pneumothorax. Child four years old. 



TUBERCULOSIS. 491 

about one-third of the deaths in childhood are due to tuberculosis in one 
form or other. While children are thus shown to be specially subject to 
this disease, they are not equally so at all ages, for Still shows that up to the 
age of 4 the percentage is as high as 71, and between 4 and 8 is still 22.5; 
after 8 it diminishes to 6.5. Moreover, the greater part of the tuberculosis 
under the age of 4 — 43.4 of the 71 per cent. — occurred in children under 
2 years of age. This great frequency of tuberculosis in infancy has been 
used as an argument in favor of the idea of infection through milk, the 
primary lesion being in the digestive tract. It is true, Still says, that in- 
testinal tuberculosis is exceedingly common in children; it existed in 52 
per cent, of his cases examined, but so also is that of the brain and meninges 
— 48 per cent. — and that of the lungs is far more frequent — 78 per cent. 

The total number of deaths reported as due to consumption in the 
United States during the census year was 109,750, of which 53,626 were 
males and 56,124 were females and the ratio of deaths from this disease 
to 1000 deaths from all known causes was 109.9. In 1890 the correspond- 
ing ratio was 122.3. 

The death rate of the colored from consumption was nearly three times 
that of the whites, and that of the foreign whites was much higher than 
that of the native whites. For the last-mentioned class the death rate for 
those having one or both parents foreign was also much higher than for 
those of native parents. 

The death rate of males from this disease was considerably higher than 
that of females. 

The total number of deaths reported as due to consumption in the 
United States in children under 15 years of age, during the census years 
1890-1900, was 8051, of which 3554 were males and 4497 were females. 

The death rate from consumption in the registration States was higher 
in the District of Columbia (305.3), which was due mainly to the large 
colored population. The next highest rate in the registration States was in 
Ehode Island, where it was 195.3. The death rate from this disease was 
higher among males than females in the cities, but lower in the rural dis- 
tricts. Excluding the District of Columbia, the highest occurred among 
males in the city of New York (265.3), and the lowest among males in the 
rural districts of Michigan. 

The following table shows that the death rates due to consumption in 
white persons under 15 years of age were highest in those whose mothers 
were born in Italy (50.7), in France (47.1), and in "other foreign" coun- 
tries (45.9) ; and were lowest in those whose mothers were born in Poland 
(11.4), in Bohemia (13.2), and in Germany (26.6). 

J. Walker Carr reports statistics of necropsies on tuberculous children- 
at the Victoria Hospital. He found 79 in which the disease most probably 
started in the chest and 20 in which it seemed to have begun in the 



492 



THE INFECTIOUS DISEASES. 
Table No. 44. 



Color and Birthplace of Mothers. 



Under 15 Years. 



White 

Colored 

Mothers born in — 

United States .... 

Ireland 

Germany 

England and Wales 

Canada 

Scandinavia 

Scotland 

Italy 

France 

Hungary 

Bohemia 

Russia 

Poland 

Other foreign 



31.8 
246.0 



27.5 

42.2 
26.6 
27.2 
34.5 
32.4 
32.9 
50.7 
47.1 
38.6 
13.2 
26.7 
11.4 
45.9 



Table No. 45. — Percentage of Deaths per 1000 from Consumption in Children from 
1 to 15 years of age {United States). 



Age. 



Males. 



Under 1 year 

1 year 

2 years 

3 years 

4 years 

Under 5 years 

5 to 9 years . 
10 to 14 years 



18.8 
9.3 
5.2 
3.3 
2.3 

38.9 
8.1 
9.5 



1900 



Females. 



17.8 

9.6 

4.8 

4.0 

2.2 

38.4 

13.2 

24.7 



Males. 



20.1 
9.7 
5.1 

2.7 
2.0 

39.6 
8.1 

10.7 



1890 



Females. 



16.5 

10.9 

5.0 

3.6 

2.8 
38.8 
11.7 

27.2 



abdomen. Here the relation between the two forms of infection is as 
1 to 4. In 26 children of early or limited tuberculosis, the thorax alone 
was affected in 12 cases, the abdomen in 7, being in the proportion of 1 to 
1.7. Of 53 tuberculous children under 2 years of age the disease most 
probably began in the chest in 43 and in only 5 certainly in the abdomen, 
the proportion in this case being as 1 to 8.6. Out of 27 children over 5 
years of age, the disease began in the chest in 12, in the abdomen in 6, the 
relation being as 1 to 2. 

Bollinger, in his address at the International Tuberculosis Congress, 
of Berlin, in 1899, quoted with approval the record of autopsies by Heller 
(Kiel) of 248 tuberculous children. In 45.5 per cent, of the cases tuber- 
culosis involved the mesenteric glands. From these it was concluded 



TUBERCULOSIS. 493 

that milk played a leading role in the so-called transmitted tuberculosis of 
children. 

It is plain from what has been said, without quoting further statistics, 
that in some countries where bovine tuberculosis is very frequent, there is 
also a great frequency of tuberculosis in children. Bollinger concludes that 
"although the tuberculosis of cattle and swine does not stand in the first 
line as source and starting point of human tuberculosis, nevertheless — con- 
sidering their enormous distribution and progressive additions, and the great 
clanger from the ingestion of the milk of tuberculous cows — they are cer- 
tainly for humanity the most important and the most dangerous of all 
animal plagues, and deserve the most earnest attention from the sanitarian 
and the state." 

Symptoms. — The more important symptoms noted in this condition are 
a general restlessness with a rise of temperature. Children frequently have 
little or no cough, but some difficulty with respiration for which no distinct 
physical signs can be found. The temperature will sometimes rise as high 
as 103° or 104° F., or it may suddenly become apyretic and assume a sub- 
normal tendency. The temperature usually seen is 101° F. The children 
appear very anaemic and at times cyanotic, mostly on the cheeks and lips. 
Emaciation usually accompanies this "intermittent type of fever" To the 
inexperienced, the beginning of a miliary tuberculosis resembles mostly the 
clinical picture which so frequently accompanies intermittent fever. There 
usually is slight swelling of the peripheral lymph glands': The spleen and 
liver will be felt enlarged. The urine will give a slight diazo reaction, also 
an indican reaction. Neither of these, however, are constantly present. We 
have what is commonly known as a "pre-tubercular anaemia," in which there 
is a general tendency to breal-doiun, and pallor so well marked, for which 
there is no distinct group of symptoms. When such profound anaemia 
exists with slight variations of temperature, then tuberculosis may be in- 
ferred; hence this stage is regarded by some clinicians as the "pre-tuber- 
cular" stage. Occasionally the examination of the chest shows catarrhal 
symptoms and rhonchi as accompany an ordinary bronchitis. There is an 
absence of bronchial breathing and no distinct evidence of dullness on per- 
cussion. Frequently these symptoms increase in severity. Cyanosis may 
accompany this condition and the circulation may be so poor as to show cold 
feet and hands. Death occasionally follows this condition. The clinical 
picture here given is the one that is frequently seen in that type of acute 
miliary tuberculosis running a malignant and very short course. In this 
condition the children appear very pale and lose v weight. There is distinct 
anorexia which alternates with hyperorexia. Dyspeptic symptoms, such as 
vomiting and diarrhoea, may alternate with constipation. Such children 
are usually very sensitive and inclined to be peevish and cry on the slightest 
provocation. 



494 THE INFECTIOUS DISEASES. 

V'Espine's Sign. — This sign is of great importance in confirming the 
diagnosis of tuberculosis in its earliest stage. In children old enough to 
repeat the words "three thirty three" the echo heard of the last word is very 
significant, and should, when present, be regarded as supporting the diag- 
nosis of tuberculosis. 

D'Espine studied 1 a series of infants and children and noted that the 
whispered voice is not heard lower than the seventh cervical spine 
posteriorly. 

If the lymph-nodes are enlarged and the patient whispers "three thirty 
three" then bronchophony is heard over the upper thoracic spine as well. 

D'E'spine's sign is best elicited 2 when the arms are folded well across 
the chest, the head sharply flexed, and the patient sitting erect. Firm pres- 
sure should be made with the stethoscope as patient repeats "three thirty 
three." When the sign is positive the final "e" of the last word persists for 
a moment like an echo after the phonation ceases. This postphonal quality 
is the significant feature. Young children can often repeat the "tree" more 
easily than the usual phrase. Occasionally the spoken voice or cough 
brings out the echoing quality more than the whisper. 

A study of the above symptoms will show that there are no distinct 
typical symptoms which can be laid down as positively diagnostic. It is 
for this reason that so many other diseases are confounded with miliary 
tuberculosis until the same has progressed considerably. When there is 
marked cachexia accompanying nurslings for which there is no distinct 
reason, and especially so if the fever accompanying the same is an inter- 
mittent type, then we should not forget the possibility of our dealing with a 
case of miliary tuberculosis. 

Case I. A child, 2 years old, was brought to my children's clinic at the New 
York Post-Graduate Medical School and Hospital, with the following history: She 
was a bottle-fed infant raised on condensed milk. The bowels were always con- 
stipated. Has had one attack of cholera infantum when eleven months old which 
caused emaciation and general atrophy. 

Present illness dates back to three months ago when child had measles fol- 
lowed by a severe broncho-pneumonia. The cough has persisted, but mostly at 
night. There was no expectoration. 

Physical Examination. — Examination reveals an emaciated, very rachitic child, 
pigeon-breasted, with decided beaded ribs. There is also a kyphosis. The abdomen 
is distended (pot-belly). The superficial veins are enlarged, the head shows 
marked frontal, parietal, and occipital rickets. Cranio-tabes is also present, so 
that we can safely call this a markedly rachitic case. At the left apex there were 
heard coarse, mucous and sonorous rales, also prolonged expiration. The right lower 
lobe had several areas of amphoric breathing, also some friction sounds and prolonged 
harsh expiration. Percussion note was dull. The morning temperature in the rectum 
was 101° F., pulse 144, respiration 40. The appetite was poor, spleen enlarged, hands 
and feet cold, and the child perspired freely. 

1 D'Espine, Bulletin de l'Acad. de MM. Paris, 1907. 

2 Stoll, Amer. Jour. Dis. of Children, Sept., 1915. . . 



TUBERCULOSIS. 495 

Diagnosis. — Tuberculosis after morbilli. 

Family History. — The father died of tuberculosis when the infant was six 
months old. The mother is still living and in apparent good health. Two other 
children in the same family show no evidence of illness. The family live in a 
rear house behind a tenement house. The weight of the child when first seen was 
sixteen pounds. 

.Treatment— An emulsion of the yolks of 6 eggs containing sugar, and 15 drops 
of creosote carbonate was fed each day. Buttermilk and the serum of bullock's blood 
was given in wineglassful doses several times a day. The child was sent to the 
country and ordered to live out of doors. The appetite improved and the cough 
lessened. From month to month the clinical symptoms gradually subsided and 
at the end of two years the physical signs in the lungs entirely disappeared, and her 
weight increased to 32 pounds. 

In this case tubercle bacilli were found in the sup turn that was vomited after a 
severe coughing paroxysm. The case is well to-day. 

Case II. A girl, 12 years old, seen by me some years ago, was brought to my 
children's clinic at the New York Post-Graduate Medical School and Hospital. She 
was suffering with headache, cough, general malaise, poor appetite, and emaciation. 
She had been under the treatment of a physician who diagnosed malaria. The 
bowels were irregular, at times constipated, at other times diarrheal. The urine, 
light amber color, contained nothing abnomal. The child perspired freely at the 
slightest exertion, even after each paroxysm of cough. 

Previous History. — She was a bottle-fed infant. Had measles and broncho- 
pneumonia at 3 years. When 5 years old had had whooping-cough which lasted 
four months. Excepting an occasional cough no other symptoms were present. 

Family History. — The family history is good. Both parents are living and 
four brothers; all are healthy. The only history as to etiology is that this girl 
has lived in unsanitary surroundings, besides having a weakened state of the 
respiratory tract. 

Physical Examination. — At the first examination she appeared slightly icteric, 
the spleen was enlarged, the liver normal. There was a slight dullness at the 
apex of the right side, some mucous rales and harsh breathing. There was a slight 
expectoration, no history of haemoptysis. Nose bleeding was complained of occa- 
sionally. The diagnosis was made by the presence of tubercle -bacilli in the 
sputum. Each month her sputum was examined, and it was found that the 
sputum which was expectorated during the early morning hours, between 4 and 6 
a.m., contained the greatest number of tubercle bacilli. After four months of treat- 
ment it was found that the bacilli in the morning sputum were so sparingly present 
that evidently some change was going on. The symptoms of headache and malaise 
disappeared entirely, The icteric condition disappeared. The epistaxis has not 
shown itself within the last five months. A careful examination of the sputum 
four times a month has not shown a single tubercle bacillus. 

The treatment consisted in removing the child from school and giving her a 
substantial diet of which proteins formed the chief part. The hygienic conditions 
were improved as much as the circumstances of the family would permit. 

I impressed the family with the necessity of removing the child to the country 
and she was given into the employ of a farmer, and ordered to be in the open air 
all of the time. Six months later I saw the case again. She had gained in weight. 
Her cough had ceased and the physical signs were lessened. 

The child lived in the country eighteen months. 



496 THE INFECTIOUS DISEASES. 

At the end of this time there was no evidence of cough nor of the general 
malaise excepting the physical signs on auscultation and percussion. I have seen 
this child in all about seven years and believe that she is quite healthy. The 
pulmonary symptoms have entirely disappeared. 

According to Loomis, tuberculosis and cavities in the lungs can and do heal. 
I have good reason to believe that in this patient, in whom we diagnosed apex tuber- 
culosis or a catarrhal tuberculosis affecting the apices of both lungs, this process 
was arrested in its incipiency. 

Diagnosis. — Method of Obtaining Sputum: In infants and young chil- 
dren who do not expectorate, the following method of obtaining sputum is 
suggested by F'indlay, of Glasgow: "With a piece of gauze on the fore- 
finger, the pharynx, and especially the epiglottis, is irritated so as to induce 
coughing, and any expectoration that is coughed up is swept out of the 
mouth before it has time to be swallowed. The quantity thus obtained 
varies, but as a rule is sufficient for bacteriological examination." 

The diagnosis will frequently be very difficult, especially so if no data 
can be obtained which will complete our clinical picture. If the child 
has been exposed to tuberculous individuals then a suspicion may arise (if 
there is a tuberculous family disposition) of a possibility of the development 
of this disease. Frequently the symptoms are such as to resemble typhoid, 
but if there is an absence of roseola, if the diazo reaction is absent, 
and if the Widal reaction is absent, then miliary tuberculosis must be 
inferred. The ophthalmoscopic examination must not be looked upon as a 
positive criterion, for miliary tuberculosis may exist in spite of the absence 
of tuberculosis of the choroid. For differential diagnosis between tubercu- 
losis and syphilis, see chapter on "Syphilis." 

Tuberculides. 

Papulo-necrotic tuberculides are round, flat papules, brownish in color. 
They have a central whitish depression and are usually covered with a small 
scale. They may occur on any part of the body. Their most frequent loca- 
tion is on the forearm, thighs, the external surfaces of the legs, and be- 
tween the thighs. They sometimes occur on the face. 

With the presence of the papulo-necrotic tuberculides aided by a von 
Pirquet skin reaction we have one of the best means at our command of 
confirming the diagnosis of infantile tuberculosis. Even though the von 
Pirquet reaction is negative, the presence of the papulo-necrotic tuber- 
culides strongly favors a diagnosis of tuberculosis. 

Hallopeau in 1896 at the Third International Dermatological Congress 
brought out the value of this lesion. 

Tuberculin Keaction an Aid to the Diagnosis of Latent 
Forms of Tuberculosis. 1 

Von Pirquet found that by inoculating the skin with a minute quantity 
of old tuberculin a local inflammatory reaction is produced. There is no 



1 Complete literature and details published in the New York Medical Journal, 
October 19, 1907. 



PLATE XVIII 




Papulo-necrotic Tuberculides in a child two years old, seen during- my 
service at the Willard Parker Hospital. A valuable diagnostic lesion of 
tlie skin. (Original.) 



TUBERCULOSIS. 497 

fever nor general systemic disturbance after such inoculation. With the 
older method of Koch fever followed each injection. The technique is as 
follows: Wash the arm with ether and scarify three small areas, but not 
enough to produce a bloody surface. Into two of the scarified areas inocu- 
late (similar to vaccination) diluted tuberculin of the strength of one part 
tuberculin with three parts normal saline solution. Leave the third scari- 
fied area without inoculation as a control. After twenty-four, rarely later 
than forty-eight, hours a local inflammatory reaction, about 10 millimeters 
in width, surrounding the inoculated area, denotes a positive reaction. In 
the last stages of miliary tuberculosis and tuberculous meningitis no reaction 
follows. The ophthalmo reaction 1 is another method of diagnosis. 

Prognosis. — The success attained during the last few years 2 in the 
treatment of tuberculosis proves the scientific progress made. Several years 
ago this disease was considered hopeless. 

Modern physicians recognize the importance of treating the collapsed 
lung that has become so through unsanitary surroundings, in the light of 
cause and effect. The prognosis therefore will depend on the age of the 
patient, the stage of the disease in which treatment is commenced, and the 
v/ill power of the patient. The vitality of children and their ability to pass 
through long periods of illness and finally recover should be remembered 
when the outcome of the case is considered. Severe forms of marasmus, 
with marked emaciation, apparently hopeless, finally recovered. I have also 
seen severe forms of apex tuberculosis in children that entirely recovered 
after proper hygienic and dietetic treatment was instituted. 

It is our duty to instruct parents and those in charge of children of the 
dangers, on the one hand, where treatment is neglected, and to picture to 
them, on the other hand, how successful other cases have been when the dis- 
ease was properly handled. 

Treatment. — Dietetic Treatment: Next to sunshine, fresh air, and 
pulmonary gymnastics comes nutrition. A child that is properly strength- 
ened with milk, buttermilk, cocoa, eggs, cereals, cheese, green vegetables, 
fruits, meats, and meat broths will certainly be better able to recover than 
one that is underfed. 

One Point Concerning Feeding. — Milk if given should not be repeated 
oftener than once in four hours. The yolk of a fresh egg may be added 
just before feeding. When soup is given the yolk of a fresh egg may be 
added to it. I frequently give the yolks of eight or ten eggs in twenty-four 
hours if the gastric condition warrants the same. Strict attention must be 
paid to the bowels so that we do not overfeed and produce a dyspepsia by 
overfeeding. If milk is not well borne it may be peptonized. 

1 Calmette advises using a V100 per cent, dilution of tuberculin dropped into 
the eye. 

2 "Tuberculosis and How to Combat It," prize essay by S. A. Knopf, is well 
worth reading. 

32 



498 THE INFECTIOUS DISEASES. 

General Treatment. — In the treatment of tuberculosis the most im- 
portant point to remember is that fresh air is the best lung disinfectant 
that we possess. No remedy will kill tubercle bacilli as quickly as sunshine 
and fresh air. This should be impressed on every family wherein a case 
of tuberculosis is found. The progress made in recent years by climatic 
treatment has demonstrated the fact that cavities in the lung will frequently 
heal under proper treatment. The open-air treatment has gained such a 
strong foothold that we do not encounter the same difficulties that we did 
years ago when recommending open windows night and day. The great 
bugbear of night air should be removed, because fresh air at night is equally 
as important as it is by day. 

Heliotherapy. — Exposing the body to sun baths in addition to living 
out-of-doors, preferably at an altitude of several thousand feet, are recognized 
as the strongest modern therapeutic measures employed. Statistics show 
the great advantage of heliotherapy in mountainous regions; on the other 
hand, we have excellent results at the sea level in tuberculous children. 1 

Pulmonary Gymnastics. — Deep inspiration and expiration will oxy- 
genate the lungs when regularly performed. 

Deep breaths taken in the mountains on which there are pine-needle 
trees will do more toward expanding and impregnating diseased or collapsed 
portions of the lung than will the inhalation of a hundred times that quan- 
tity of pine-needle oil in the close, stuffy room when diffused from an atom- 
izer. The hygienic treatment must not be confined to walking and breath- 
ing the pure air, but must be aided by tepid bathing and by stimulating the 
circulation of the blood by friction with a coarse Turkish, towel. Sea salt 
can be added to the bath. When the feet or hands are cold they should be 
briskly rubbed until the blood circulates freely. 

Medicinal Treatment. — Codliver-oil internally should be tried. If it 
is not well borne it can be used by external friction over the whole body,, 
daily for ten or fifteen minutes. This is the so-called codliver-oil bath. 
If codliver-oil is not tolerated, butter should be given in large quantities. 
Codeine in 1 / 10 - to 1 / 4 - grain doses can be given, or heroin in 1 / 50 - to 1 / 25 - 
grain doses, three times a day, may be given to relieve cough. For the 
relief of the night sweats sulphate of atropine, 1 / 150 to 1 / 100 of a grain, 
three times a day, should be given. Toxic symptoms should always be 
looked for in the pupils when administering these drugs. A laxative dose 
of citrate of magnesia or calcined magnesia, 5 to 10 grains, several times a 
day, is useful. 

If blood is expectorated, then 5 to 15 drops -of fluide^tract of ergot 
can be given every few hours. In other cases 5 to 10 grains of powdered 
alum, repeated every few hours, may do good. I have also seen good results 



1 See report of Dr. John Winters Brannan on Results with Heliotherapy at 
the Seaside Hospital, Coney Island, 1913. 



PLATE XIX 



Old Tuberculin, 
Undiluted 



Dilution — 1 : 4 



Dilution— 1 : 16 

Dilution— 1 : 64 

Control, Not 
Inoculated 




Cutaneous Reaction Showing the Various Results with Concentrated and 
Diluted Tuberculin. Taken 48 hours after inoculation by Dr. Henning, at the 
clinic of Escherich. 



PLATE XX 




Severe Cutaneous Reaction. Note the two places inoculated. The center 
is the control. (Escherich's clinic.) 




Scrofulous Reaction. Two outer places inoculated. The 
center is the control. (Escherich's clinic.) 



TUBERCULOSIS. 499 

from 5- and 10- grain doses of gallic acid. Fluidextraet of hydrastis cana- 
densis, 3 to 10 drops, several times a day, or hydrastinine hydrochlorate, 
Vioo grain, three times a day, may be tried. 

Tincture of iron, in 5- to 10- drop doses, is a good hemostatic; besides 
it is a valuable tonic. Stimulation is sometimes required. Gymnastics and 
exercise should be ordered. These must, however, be supervised, so that 
fatigue is avoided. Besides stimulating the circulation, exercise aids in the 
metabolism of food. 

We must not consider a case cured when all active symptoms subside, 
but must persist with climatic treatment for many years, to avoid a 
reinfection. 

Attention should be directed to the upper air passages and adenoids 
and tonsils removed if the slightest evidence of symptoms is noted. 

To prevent the recurrence of tuberculous infection we must remove 
the patient from his former surroundings and keep him away from them 
after improvement is noted. There is danger of reinfection in taking a child 
from an out-door life of sunshine and fresh air back to an unsanitary 
home. We should impress the family with the importance of continuing 
thorough oxygenation of the lungs night as well as day, and keeping the 
skin healthy by frequent tub baths. Out-door exercise should be advised, 
both for its stimulating effect on the circulation, as well as for its value 
in aiding food metabolism. 

Tuberculin. — The use of injections of tuberculin for diagnostic as well 
as therapeutic results dates back to 1891, when Koch first announced clin- 
ical results. My experience with tuberculin at that time, through the 
courtesy of George F. Shrady, at the St. Francis Hospital, New York, 
was not very encouraging. I have also seen cases in which tuberculin was 
used through the courtesy of Prof. Adolph Baginsky, at the Berlin Chil- 
dren's Hospital. Baginsky has never encouraged the use of these injections. 
In his sixth edition of "Lehrbuch der Kinderkrankheiten," 1899, page 
350, he says : "I do not believe that the injection of tuberculin, especially 
in very small children, is without danger. I am aware that Kossel, in 
Berlin, uses the injections very extensively and without ill results." In 
young children a dose of 1 / 500 oo milligram should be given, and two weeks 
later followed by an injection of V25000 milligram. The injections should 
be given in the evening, and local as well as constitutional symptoms care- 
fully noted. These injections should be given about once a week and the 
dose gradually increased, so that at the end of two months 1 / 5000 milligram 
can be injected without producing severe reaction. 



CHAPTER VI. 
DIPHTHEROID. 

This term we owe primarily to the French. It was introduced into the 
German literature by Professor Baginsky, and, after him, by Escherich, 

This disease is caused by an infection resulting from a series of germs, 
chiefly streptococci or staphylococci. It is a disease which differs entirely 
from diphtheria. It is not a serious disease. There are no Klebs-Loefner 
bacilli present. The usual evidences of systemic infection are absent. The 
child shows the clinical evidences of an infection in a milder form than is 
usually met with in diphtheria. The prognosis is good. The treatment 
should be directed toward restoring the normal condition of the body, and 
hence the saccharated carbonate of iron given in 5- to 10- grain doses, three 
or four times a day, is very useful. Locally, an astringent antiseptic gargle, 
consisting of equal parts of DobelPs solution and of warm water, to be used 
every hour for gargling, or a 1 to 5000 bichloride of mercury solution is 
very useful. Normal salt solution is also recommended. 

The nutrition of the body will be the means of restoring the functions 
to their normal state. It is important, therefore, to feed in regular inter- 
vals milk, soup, broth, and eggs, if they can be assimilated. If the child 
is a bottle baby or a nursling at the breast, then a smaller quantity of food 
should be given, and if the same is not taken by the mouth then rectal ali- 
mentation will be urgently called for. It is wise to isolate each and every 
form of diphtheroid affection and thus prevent the possibility of the trans- 
mission of this infection. 

Pseudo or False Diphtheria. 

Under this general title are included all cases of pseudo-membranous 
or exudative inflammation of the mucous membranes in which the diph- 
theria bacilli are absent. 

Since Loeffler, in 1889, first described a class of pseudo-membranous 
inflammations of the throat in which the diphtheria bacilli were absent 
and cocci present, it has been established that a certain portion of the 
inflammations of the respiratory mucous membranes, which closely re- 
semble the less characteristic cases of diphtheria, are not due to the diph- 
theria bacilli, but to cocci, especially to streptococci. 

It has been found that streptococci are commonly present in the throats 
of healthy persons, or at least in the throats of persons living in large cities, 
and that other forms of cocci, especially the pneumococci and staphylococci, 
are apt to be associated with them. 

These germs seem to live in the throat without creating any disturb- 
ance there, so long as the mucous membranes are healthy; but under eer- 
(500) 



PSEUDO-DIPHTHERIA. 501 

tain conditions, as when the mucous membrane has been made vulnerable 
by exposure to cold or other deleterious influences, or by the poison of scar- 
let fever, measles, or some other disease, the streptococci, alone, or asso- 
ciated with other cocci, are able to attack the mucous membrane and to 
cause an inflammation. This may be of any degree of intensity, from a 
simple inflammatory hyperaemia to an inflammation with an extensive 
production of pseudo-membrane or with ulceration. Such inflammations 
when associated with the formation of pseudo-membrane are known as 
pseudo-diphtheria. The exudate or pseudo-membrane in pseudo-diphtheria 
is usually confined to the tonsils, but other parts, such as the larynx, 
pharynx, and nostrils, may be invaded. 

It has been found that the percentage of mortality in these cases is far 
less than in diphtheria, and that the disease is seldom, if ever, commu- 
nicated to others. 

The Proportion of Cases of Suspected Diphtheria which upon Exami- 
nation Prove to be True Diphtheria. — "As soon as careful investigation 
had demonstrated it was possible, with proper precautions, to separate by 
bacteriological examination the cases of the true from those of the false 
diphtheria, large numbers of cases suspected to be diphtheria were exam- 
ined bacteriologically. The reports from hospitals in which all cases of 
suspected diphtheria were examined, are of special interest as showing the 
proportion of cases of true to false diphtheria. The results from these hos- 
pitals are all the more valuable because they come from all parts of the 
various cities in which the respective hospitals were located, and hence 
special local conditions were not likely to greatly influence the. result ob- 
tained. Thus, Baginsky, in Berlin, found the diphtheria bacilli in 120 
out of 244 suspected cases; Martin, in Paris, 126 out of 200; Park, in 
New York, 127 out of 244; Janson, in Switzerland, in 63 out of 100, and 
Morse, in Boston, in 239 out of 400. Thus, from 20 to 50 per cent, of the 
cases sent to diphtheria hospitals did not have diphtheria. 

"If we examine the reports of examinations made under some special 
conditions, as during an outbreak of some contagious disease in a hospital 
for children, we find the results may differ in a striking manner. 

"Thus, in 1889, Prudden made bacteriological examinations of 24 
fatal cases of pseudo-membranous inflammation of the tonsils, pharynx, and 
larynx. In none of these were the Loefner bacilli found to be present. 
These cases occurred in two hospitals for children in New York in which 
both scarlet fever and measles were at the time prevalent. During the past 
year we have examined the exudate from 46 fatal cases of suspected diph- 
theria occurring in these same institutions, and found the bacilli present in 
44 of them." 

If scarlet fever and measles (but not true diphtheria) were prevailing 
in an institution, it is evident the bacilli would be absent from the pseudo- 



502 THE INFECTIOUS DISEASES. 

membranes occurring in the throat as a complication of these diseases. All 
observers have found the mortality far higher in those cases in which the 
diphtheria bacilli were present than in those in which they were absent. In 
true diphtheria the mortality has been found to vary from 25 to 70 per 
cent., while in pseudo-diphtheria it varies from per cent, to 20 per cent. 

Diphtheria. 
Diphtheria is an acute infectious disease caused by the invasion of a 
specific micro-organism known as the Klebs-Loeffler bacillus. 

It is a disease characterized by the presence, locally, of false mem- 
branes, known as pseudo-membranes. 

The presence of pseudo-membrane is frequently caused by the strepto- 
coccus. The Klebs-Loeffler and the streptococcus varieties are identical in 
their clinical manifestations. 

Etiology. — This disease is most frequently met with in children, al- 
though adults are not exempt from it. It is met with in the newly born 
(Jacobi). It is most frequently seen between the fourth and tenth years. 
Children are especially disposed to this disease between the ages of 1 and 
5 years. Baginsky reports a series of 2711 cases in which: — 
84 occurred during the first year. 
889 between the first and fourth year. 
1411 between the fourth and tenth year. 
318 between the tenth and fourteenth year. 

There is no difference in the sex regarding the predisposition to 
diphtheria: — 

1311 in the above series were boys. 
1400 were girls. 

Infection is spread primarily by . contact. It can be transmitted 
through dishes, play toys, and furniture to which the Klebs-Loeffler bacilli 
adhere. Infections have been traced to water and milk which contained 
the diphtheria bacillus. We know that the Klebs-Loeffler bacilli adhere 
to the walls and ceilings of rooms. The etiology of diphtheria remained 
obscure until Loeffler discovered the bacillus in 1884. 

Kissing a child, sick or convalescing from diphtheria, is a direct 
method of contracting the disease. 

Unhealthy Throats.— Diseased, tonsils, or adenoid vegetations in the 
pharynx, are usually foci for the development and propagation of the Klebs- 
Loeffler bacillus. This has been repeatedly verified by me during many 
years of service at the Willard Parker and Riverside Hospitals. 

Thus it would appear wise to put the throat in as healthy a state as 
possible in order to guard against the development of this disease. 

False diphtheria, in which there is a non- virulent germ present, fre- 
quently resembles diphtheria. 



DIPHTHERIA. 



503 



Hunt's differential stain and also the ISTeisser stain will differentiate 
the non- virulent from the virulent form of germ. 

Table No. 46. — Diphtheria Cases Under 18 Years. Willard Parker Hospital. 







"3 
o 

a 

a 


a 
u 

0) 

a 


CD 
S-i 
33 
O 
>H 
CN 
O 

43 


CO 

u 

a 
o 

>H 
CO 
O 


o5 
a 

o 


c* 
u 

m 

cu 

to 
o 


S-l 

ca 
<u 

to 

o 


w 
u 

c3 
<u 

l> 

O 


CO 

c3 

CO 

o 


03 

o 

O 

o 


cc 
u 

c3 
<V 

<N 

C 


cc 

S-. 

O 

o 


3 

CJ 
CO 

o 






5 


P 


"■■ 


CN 


CO 


■^ 


m 


to 


t^. 


cc 




rH 


" 




Male 


798 


49 


159 i 138 


121 


87 


62 


33 


31 


28 


30 


33 


27 


1910 


Female 


733 


30 


. 107 110 


103 


77 


75 


72 


38 


39 


33 


24 


25 




Total 


1531 


79 


266 248 


224 


164 


137 


105 


69 


67 


63 


57 


52 




Male 


530 


29 


i 139 102 


50 


58 


33 


23 


12 


35 


20 


15 


14 


1911 


Female 


760 


62 


158 90 


104 


109 


62 


42 


20 


30 


25 


30 


28 




Total 


1290 


91 


■. 297 192 

1 


154 


167 


95 


65 


32 


65 


45 


45 


42 



Table No. 47. — Per cent, of Mortality from Diphtheria in Different 
Cities of the United States. 



Cities. 


Treatment. 


1895. 


1896. 


1S97. 


1898. 


1*99. 


1900. 


1901. 


1902. 


Baltimore, Md. 
Baltimore, Md. 


No antitoxin . 
With antitoxin . 






19.83 
■ 9.8 


17.52 

9.8 


15.01 
9.8 


14.62 

8.3 


13.37 

6.87 










Lowell, Mass. 
Lowell, Mass. 


No antitoxin . 
With antitoxin 
i 


48.0 
28.0 


56.0 
10.0 


27.0 
9.0 


35.0 

9.0 


39.0 
12.0 


30.0 
4.0 


30.0 
11.0 


26 

8.0 


Newark, X. J. 
Newark, N. J. 


No antitoxin .. 
With antitoxin 


23 
13.0 


31.0 
11.0 


19.0 
11.0 


17.5 

10.5 


14.5 

8.77 


14.6 
8.1 


22.7 
6.6 


19,0 

70 


Rochester, N.Y. 
Rochester, N.Y. 


No antitoxin . . . 
With antitoxin 


22.7 
12.24 


21.7 
9.6 


23.9 
9.0 


17..-) 
9 7 


18.7 
6.5 


8.9 
8.4 


■10.96 
6.97 



Bacteriology. — In the year 1883 bacilli which were very peculiar 
and striking in appearance were shown by Klebs to be of constant oc- 
currence in the pseudo-membranes from the throats of those dying of 
true epidemic diphtheria. One year later Loeffler published the results 
of a very thorough and extensive series of investigations on this subject. 
He found the bacillus described by Klebs in most but not all cases of 
throat inflammations which had been diagnosticated as diphtheria. He 
separated these bacilli from the other bacteria present and obtained them 
in pure culture. When he inoculated these bacilli upon the abraded mucous 
membrane of susceptible animals, pseudo-membranes were produced, and 
frequently death followed. If a certain amount of a bouillon culture was 
injected subcutaneously into guinea pigs, death was caused with charac- 
teristic lesions. Loeffier's failure to find the bacilli in every case examined 



501 THE INFECTIOUS DISEASES. 

is now explained by the fact that certain varieties of pseudo-membranous 
inflammation caused by the streptococcus bacillus, such as occur especially 
in scarlet fever, were then wrongly considered to be true diphtheria. 

Welch in an address on diphtheria said : "All the conditions have been 
fulfilled for diphtheria which are necessary to the most rigid proof of the 
dependence of an infectious disease upon a given micro-organism, viz. : the 
constant presence of this organism in the lesions of the disease, the isolation 
of the organism in pure culture, the reproduction of the disease by inocula- 
tion of pure cultures, and similar distribution of the organism in the 
experimental and the natural disease. In view of these facts we must agree 
with Prudden that we are now justified in saying that the name diphtheria, or 
at least primary diphtheria, should be applied, and exclusively applied, to 
that acute infectious disease usually associated with pseudo-membranous 
affections of the mucous membrane which is primarily caused by the bacillus 
diphtheria? of Loeffler." 

The germs cannot be found in the blood, but usually in the 
membranes. Now and then the specific germ may not be easily found 
in the pseudo-membranes. When such is the case, several cultures may be 
necessary to demonstrate the presence of the Klebs-Loeffler bacillus. This 
bacillus is most easily found in the older pseudo-membranes. 

Frequently we find the streptococcus or the staphylococcus accom- 
panying the Klebs-Loeffler bacillus. We are not justified in pronouncing 
the visible pseudo-membrane diphtheria unless we find the Klebs-Loeffler 
bacillus present. 

When there is a pseudo-membrane present and the Klebs-Loeffler ba- 
cillus cannot be found, then a provisional diagnosis of diphtheria can be 
made. 

Technical errors will sometimes occur in the taking of cultures or in 
inoculating culture media. Thus, the germ may not be found. The rule 
always followed by the writer is to isolate every patient having visible mem- 
branes until the same have disappeared. 

The bacillus can frequently be transmitted through animals. Cows, 
cats, dogs, and pigeons having diphtheria can easily infect those coming 
into contact with them. Cows' milk can transmit the disease if the Klebs- 
Loeffler bacillus exists therein. 

Characteristics of the Loeffler Bacillus. — The diameter of the bacilli 
varies from 0.3 to 0.8 micro-millimeters, and the length from 1.5 to 6.5 
micro-millimeters. They occur singly and in pairs, and very infrequently 
in chains of three or four. The rods are straight or slightly curved, and 
usually are not uniformly cylindrical throughout their entire length, but 
are swollen at the ends, or pointed at the ends and swollen in the middle 
portion. Even from the same culture different bacilli vary greatly in their 
shape and size. The two bacilli of a pair may lie with their long diameter 



DIPHTHERIA. 505 

in the same axis, or at an obtuse or an acute angle. The bacilli possess 
no spores, but have in' them highly retractile bodies. They" stain readily 
with the ordinary aniline dyes and retain their color after staining by 
Gram's method. With an alkaline solution of methylene blue, the bacilli, 
from blood serum especially, and from other media less constantly, stain in 
an irregular and extremely characteristic way, namely, club-shaped. 

The bacilli do not stain uniformly. Certain oval bodies situate in 
the ends, or in the central portions, stain much more intensely than the rest 
of the bacillus. Sometimes these highly stained bodies are thicker than the 
rest of the bacillus ; again, they are thinner and surrounded by a more slightly 
stained portion. The bacilli seem to stain in this peculiar way at a certain 
period in their growth, so that only a portion of the organisms taken from 




Fig. 157. — Diphtheria or Klebs-Loeffler bacilli; smear preparation from ton- 
sillar deposit. LoefflerJs stain. X 800. ( Lenhartz-Brooks. ) 

a culture at any one time will show the characteristic staining. In old 
cultures it is often difficult to stain the bacilli, and the staining, when it 
does occur, is frequently not at all characteristic. 

Growth on Blood Serum. — If we examine the growth of the diph- 
theria bacillus in pure culture on blood serum, we will find at the end of 
ten to twelve hours little colonies of bacilli, which appear as pearl-gray or 
whitish-gray, slightly raised points. The colonies when separated from each 
other may increase in forty-eight hours, so that the diameter may be % 
inch. The borders are usually somewhat uneven. These colonies, lying 
together, fuse into one mass, especially if the serum is rather moist. During 
the first twelve hours, the colonies of the diphtheria bacilli are about equal 
in size with those of the streptococci; but after this time the diphtheria 
colonies become larger than those of the streptococci, nearly equaling those 
of the staphylococci. 



506 



THE INFECTIOUS DISEASES. 



The Relation Between the Length of the Bacillus and its Virulence. — 
Some investigators believed that the degree of virulence possessed by the 
diphtheria bacilli could, to a certain extent, be judged by their length. 







■^ 



a. 



p? ":~::¥- 






Fig. 158. — True and False Diphtheria, {a) Diphtheria bacilli X100; 
(&) characteristic diphtheria bacilli X1000; (c) colonies of diphtheria 
bacilli X124; (d) even-stained short diphtheria bacilli X1000; (e) pseudo- 
diphtheria bacilli X 1000; (f) streptococci smeared directly upon cover glass 
from throat exudate X 1000. (After Park.) 

The longest bacilli were supposed to be the most virulent; those of medium 
length less so, and the shortest, little if at all virulent. By observing 
this characteristic it was thought cultures might become helpful in 
prognosis. 

"The short Klebs-Loeffler bacillus apparently produces a toxin of 



DIPHTHERIA. 507 

greater virulency than the larger forms, although the local manifestations 
may not be so extensive. 1 

"The long Klebs-Loeffler bacillus and the streptococci, when found 
alone, give rise to a mild type of the disease. 

"The streptococcus is found associated with Klebs-Loeffler bacillus in 
most severe cases. Its special significance is not so clear, but it is possible 
that by causing a more intense inflammatory reaction it opens avenues by 
which the toxins of the Klebs-Loeffler bacillus, plus its own toxin, may find 
more ready entrance into the circulation. 

"The apparent beneficial action of the antitoxin of the Klebs-Loeiner 
bacillus in cases where this bacillus is not present may be due to the fact that 
though the local action of the different microbes varies to a considerable ex- 
tent, the action of their toxins, as is shown by the similarity of the constitu- 
tional symptoms produced by them, presents many kindred features. The 
thought therefore arises that the antitoxin of one infection may have an in- 
hibitory effect on the toxin of another." 

Very careful notes have been made on this point in the examination of 
the bacteria from the original serum tubes in the following 1613 cases : — 

Table No. 48. 





No. of Cases. 


Mortality. 


Bacilli of average size found in 


1398 
82 
67 

66 


26 per cent. 

27 per cent. 
35 per cent. 

12 per cent. 


Bacilli longer than average in 


Bacilli shorter than average in 


Bacilli short, not characteristic in shape and evenly 
stained, of which many were pseudo-diphtheria bacilli. 


Number of cases examined 


1613 





"The results obtained from this examination of 1613 cultures, therefore, 
indicate that in New York the great majority of cases of diphtheria yield in 
cultures bacilli of medium size which are characteristic in shape and man- 
ner of staining. In a moderate number of cases the bacilli found are much 
longer, and in about an equal number they are much shorter. Both the 
clinical histories and the animal experiments show that whenever in their 
shape and in the way in which they take the staining fluid the bacilli are 
characteristic, no information as to their virulence, either in men or ani- 
mals, can be gathered from their length. Those bacilli, on the other hand, 
which are short and stain uniformly with methylene blue usually prove to 
be of the pseudo-diphtheria type, and have no virulence in animals." 

Pathology. — The pathological lesions are caused by the specific action 
of the Klebs-Loeffler bacillus and the associated pathogenic bacteria. In 



X N. J. Class (N. Y. Medical Journal, May 14, 1897) 



508 



THE INFECTIOUS DISEASES. 



addition thereto the toxins generated by the various micro-organisms pro- 
duce local destructive changes. 

As a rule, the local pathological lesion is a whitish, yellowish-white, 
or grayish-white membrane, which is firmly adherent. In some instances 
a distinct greenish or black color (gangrenous type) is evident. 

In a study of the pathology of 220 fatal cases of diphtheria by Mal- 
lory, Councilman, and Pearce they found two varieties of membrane; first, 
a dense, firm, elastic membrane composed of a reticular structure with 
considerable uniformity in the size of the beams composing it. This mem- 
brane can be stripped off in large flakes. Second, a more friable variety 
composed of fibrin forming a reticulum with more irregular spaces and 
fibers. The fibrin spaces contain leucocytes, amongst which are found some 
broken clown cells (detritus). The epithelium below the membrane con- 
tains polynuclear leucocytes and lymphocytes. 

The interval lesions of diphtheria are those resulting from degenerative 
changes affecting organic structures. As a rule, haemorrhages are found in 
addition to marked degeneration. The lymph nodes are usually swollen 
and contain small foci of cell-necrosis. Broncho-pneumonia, if present, 
shows the usual lesions common to this condition. The nervous system, 
heart, spleen, lungs, and liver show the most destructive effect of the toxins 
of diphtheria. 

Table No. 49. — Two hundred an I nine cases of Diphtherial studied by Councilman, Mallory, 

and Pearce, of Boston, in 1901, showing the percentage of cases in which 

th° different bacteria were found by culture 





Heart's Blood. 


Liver. 


Spleen. 


Kidneys. 


Diphtheria Bacillus , . 
Streptococcus .... ... 

Staphylococcus Aureus . 
Pneumococcus . . , . . 


6 per cent 
20 " 
2.5 " 
1.5 " 


20 per cent. 
30 " 
4 

2.5 " 


12 per cent. 
27 

3 

1.5 " 


19 percent. 

28 " 
8 
5 



The Blood. — John S. Billings, Jr., 1 says: — 

1. The red corpuscles of the blood in diphtheria undergo a diminu- 
tion in number in cases of moderate severity and in severe cases. Eegen- 
eration is slow. 

2. The leucocytes are increased in numbers in all but two classes of 
cases, exceptionally mild cases and exceptionally severe ones. As a rule, 
the amount of leucocytosis is directly proportionate to the degree of severity 
of the case. The leucocyte-curve shows no correspondence to the clinical 
course of the disease. The number of leucocytes often remains higher than 
normal for days after all inflammation has disappeared. The leucocytosis 
is similar in character to that seen in pneumonia and scarlet fever, the 
increase of the leucocytes being in the so-called polynuclear forms. 



Annual Report, Health Department, 1897. 



DIPHTHERIA. 



509 




f% 







Fig. 159.. — Section from an inflamed uvula covered with a stratified 
fibrinous membrane, from a case of diphtheritic croup of the pharyngeal 
organs (Mutter's fluid, hematoxylin, eosin). (a) Surface layer of coagulum, 
consisting of epithelial plates and fibrin and containing numerous colonies 
of cocci; (b) second layer of coagulum, consisting of fine-meshed fibrin net- 
work enclosing leucocytes; (c) third layer of coagulum, lying upon the con- 
nective tissue, and consisting of a wide meshed reticulum of fibrin enclosing 
leucocytes; (d) connective tissue infiltrated with cells; (e) infiltrated bound- 
ary layer of the connective tissue of the mucous membrane ; (f) heaps of red 
blood-cells; (g) widely dilated blood-vessels; (h) dilated lymph-vessels filled 
with fluid, fibrin, and leucocytes; ft) duct of a mucous gland distended with 
secretion ; (kj transverse section of a gland ; (I) fibrin reticulum in the super- 
ficial layer of connective tissue. X45. (Ziegler.) 



510 THE INFECTIOUS DISEASES. 

3. The percentage of haemoglobin falls eoincidently with the number 
of the red blood-corpuscles, and to the same relative degree. But the 
regeneration of the haemoglobin takes place much more slowly than that 
of the red blood-corpuscles. 

4. In cases treated with antitoxin the diminution in the number of 
the red corpuscles is much less marked than in those cases treated without 
it; in a majority of cases no such diminution takes place. The leucocytes 
are apparently unaffected by the antitoxin. The haemoglobin is also much 
less affected in the cases treated with antitoxin, thus confirming the state- 
ment as to the red corpuscles. 

5. In healthy individuals injected with antitoxin, the red corpuscles 
show a very moderate reduction in number in about one-half the cases. 
The haemoglobin is correspondingly affected. The leucocytes are apparently 
unaffected by the injections. 

6. No peculiar characteristic changes in the morphology of the cor- 
puscles were to be made out. 

7. It is improbable that any information of prognostic importance is 
to be gained by the examination of blood in diphtheria. 

8. The antitoxin treatment of diphtheria has no deleterious effects 
upon the blood-corpuscles. On the contrary, it seems to prevent degenera- 
tive changes which would otherwise be brought about. 

The Effect of Diphtheria Toxin on the Nervous System.- — E. Luisada 
and D. Pacchioni 1 report the results of a number of experiments with diph- 
theria toxin on dogs : — 

1. The diphtheria toxins applied directly to the nervous system pro- 
voke a profound lesion at the point of application, characterized by an 
inflammatory and degenerative action. 

2. These lesions are propagated more or less extensively from the 
point of application. 

3. In non-immunized dogs, which had been injected with a dose suffi- 
ciently toxic, the phenomena of local reaction were noted. 

4. In immunized dogs the toxins constantly produced alterations in 
the central nervous system, intense, localized, but of less extent than those 
produced in dogs non-immunized. 

5. The toxin applied directly to the medulla is propagated rapidly in 
all directions, preferring the posterior columns, the gray matter, and the 
central canal, as routes. In consequence of the bulbar invasion death 
occurred in the animals more rapidly when the toxins were introduced into 
the medulla than when applied to any other portion of the cerebro-spinal 
axis. When the toxins were introduced into the cerebral cortex, character- 
istic lesions of these regions were manifested. Death occurred later through 
propagation of the poison to the medulla. 

1 Giomale della "R. Accademia di Medicina di Torino, vol. Ixi. 



DIPHTHERIA. 51 1 

6. Toxins introduced into the sheath of the sciatic nerve provoked an 
inflammatory process more or less intense, but more circumscribed than in 
the central nervous system. From the nerves the poison ascended to the 
medulla, chiefly through the posterior columns, and thus provoked an as- 
cending myelitis. 

7. The lesions produced upon the neuroglia by direct action of the toxins 
are similar to those reported by Vassale, Donaggio, and others in the various 
intoxications and infective processes. In the oblongata the prevalent alter- 
ations are found in the crossed pyramidal tracts and posterior columns. 

8. The alterations produced by the toxins affect the nerve fibers more 
than any other part of the nervous tissue. These lesions affect principally 
the myelin, and consist of a physical modification of it, whereby the con- 
nections between the various nerves are lost. There is partially a chemical 
modification of the myelin also present. 

9. The local action of the toxins has much importance in the genesis 
of various paralyses as seen in the human family, attacking first the sheaths 
of the nerves, then the nerves, and later the nerve centers of the medulla. 

Action of Diphtheria Poison on the Heart. — F. Bolly, first as- 
sistant to the children's clinic at Heidelberg, as the result of a series of 
experiments on animals with the diphtheria toxin, 1 concludes that: — 

1. The fall in blood-pressure induced by the poison of diphtheria is 
due to paralysis of the vasomotor center, and also to the paralysis of the 
heart, which in spite of artificial respiration soon ceases to beat. 

2. This action on the heart is direct, and in warm-blooded animals is 
in dependent of the nervous system. 

3. The paralysis of the heart develops after a more or less definite 
latent period. Direct injection of the diphtherial poison or transfusion of 
lethal diphtherial blood interferes with the action of the isolated normal 
rabbit's heart only after a certain latent period. 

4. On the other hand, the action of the poison takes place at the same 
time, even if, before the appearance of poisonous symptoms or at the be- 
ginning of such toxic action, the heart is washed out with normal blood. 

5. This property possessed by the diphtheria poison of action on the 
heart leads to the opinion that the poison gradually takes hold of the heart 
muscles, and is seemingly stored up there until its complete action is mani- 
fest; this further explains the continuance of functional heart disturbances 
after many of the acute infections. 

Symptoms and Course. — Considering the clinical picture of this dis- 
ease, the following classification would appear most plausible: 

1. Mild dipJitlieiia. 

2. Severe diphtheria. 

3. Septic diphtheria. 



'Archiv fur experimentelle Pathologie u. Pharmakologie," 42, 1S99. 



512 THE INFECTIOUS DISEASES. 

Mild diphtheria usually commences with symptoms of malaise. The 
appetite is poor; the tongue is coated, and the lymph glands at both sides 
of the jaw are swollen. The pharynx is reddened. The mucous membrane 
is swollen and the tonsils are covered with small, grayish-yellow plaques, 
which adhere very firmly. On attempting to remove a piece of membrane 
a bleeding surface remains. This membrane peels off gradually, but leaves 
a red line of demarcation on the tonsils. A close study of the tonsil will 
show the former size of this pseudo-membrane. Usually the color of the 
pharynx returns to normal; sometimes it is rather anaemic, and after a 
few days the scar will show the presence of the former affection. When, 
however, this condition does not resolve in a few days, then there is always 
danger of a systemic infection. A small, apparently innocent patch on 
the tonsil or pharynx should be as vigorously treated as a general septic 
infection. In other words, the danger of a small patch extending to the 
larynx should not be forgotten. Other forms of local affections are: 
Sometimes the lips or the nose, the mucous membrane of the mouth, 
the tongue, the vagina, and the skin are the seat of a diphtheritic infec- 
tion. Not infrequently diphtheria affects the umbilicus. Such diphtheritic 
omphalitis is exceedingly dangerous and frequently fatal. Ehinitis, espe- 
cially in young infants, is frequently a diphtheritic process, although re- 
sembling an ordinary "cold in the head." The sudden appearance of croup 
will frequently cause a fatal termination if neglected. 

Severe Diphtheria. — This condition usually commences with fever. 
The temperature varies between 101° and 102° F. If children are. old 
enough they will complain of chills. It is not uncommon to have con- 
vulsions. The cheeks are usually flushed; in some instances they are very 
pale. The mucous membrane of the mouth is reddened. The pharynx has 
a dark-red color. The tonsils are swollen. Both' tonsils are intensely 
congested and covered with a yellowish or yellowish-gray membrane. The 
uvula is usually involved. There is pain on swallowing and a decided nasal 
tone of voice. The submaxillary glands are swollen. The nose discharges 
an acrid fluid containing yellowish shreds or flakes. In many cases after 
careful treatment the appetite returns. The diphtheritic patches are 
limited in area. The intense swelling and congestion fades. The mucous 
membrane appears and the swelling of the submaxillary glands subsides, so 
that conditions resume their normal state. On the other hand, the affection 
may spread from the pharynx and involve the velum palatinum and extend 
downward so that the larynx is involved, causing stenosis and other serious 
symptoms. 

Septic Diphtheria. — In this type of diphtheria the resemblance to a 
typhoidal condition associated with profound toxaemia is noted. In septic 
diphtheria the general manifestations resemble a severe form of typhoid. 
The tongue is shining and dry. The submaxillary glands are very much 



DIPHTHERIA. 



513 



swollen. The children appear puffed, and the face has a pale, waxy appear- 
ance. The extremities are cool. The heart sounds are weak, sometimes 
inaudible. The pulse is small, sometimes thready, and can be counted with 
difficulty. There is severe constipation, rarely diarrhoea. The .brain is clear, 
although the children appear in a semi-comatose condition, moaning and 
with mouth open. The urine is diminished and contains albumin and also 
epithelium. There is a general apathetic condition, with cardiac weakness. 
In other instances there is a decided hemorrhagic tendency. Hemorrhagic 
spots appear. on the skin. The urine is bloody. The stools contain blood. 



19 aa. 


DATES OF OBSERVATIONS 


&M 


ft. 


6 


7 


8 


9 


10 


11 


12 


13 


Cent! 


^Fahr, 


AM>M 


am:pm 


am!pm 


am:pm 


am>m 


am!pm'am:pm 


am'pm 


39°~ 

38°~ 


;6 
: 102° : * 
















§ 


•6 

: ioi°- * 




i"*t 


A 










/8 


•8 
•6 

: ioe° : 2 


li 


t\ 


. 1 


\ 








i 


37°" 

A'arwal 

36 °~ 


•8 

•6 

- o*4 

-99 •* 








; \ 


>./ 


\ 


<il 


: 


• 8 

•6 


















-98 ' ■* 












: 




•8 

•0 

o' i 

•97 -2 


















•8 

• e 

- o-* 

-96 'i 


















Pulse 
per minute 


IS 

1 V. 




35 




3? 


3|S 


^S 


ss 


Respirations 
per minute 


1** 






^ 











Fig. 160. — Septic Type of Diphtheria Complicated by Myocarditis. 
The effect of the poison is shown on the heart. Note the pulse-rate, low 
temperature and the respiration. (Original.) 



Expistaxis is frequent. There is a general somnolence. A tendency to 
collapse, ending fatally. 

The diagnosis depends on the presence of a membranous exudate cover- 
ing the tonsils and pharynx. This type of disease is usually associated 
with nasal diphtheria. There is a foul-smelling discharge, sometimes a 
marked gangrenous odor, from both nose and mouth. When the membrane 
exfoliates it is not uncommon to have severe epistaxis. The temperature 
ranges between 100° and 101° ; at times subnormal temperatures are 
encountered. There is a tendency to collapse. 

Nasal Diphtheria. — The nasal infection may be an extension from the 
pharynx upward, or the disease may be confined to the nose and localized 
there. Vigorous treatment should be installed early in the disease. Owing 



514 



THE INFECTIOUS DISEASES. 



to the large amount of lymphoid tissue in the naso-pharynx, the tendency 
to profound toxaemia from absorption should be remembered, and the 
toxin inhibited by early and active treatment. 

When there is a general infection, then greater attention should be 
paid to the condition of the heart. The pulse is usually small and thready. 
The heart sounds are feeble; sometimes they are muffled. In other in- 
stances there is a tachycardia. The extremities are usually cold. If these 



Oct. 


15 


16 


17 


18 


19 


20 


21 


22 


Fahr. 


AM. PM. 


AM. PM. 


AM. PM. 


AM. PM. 


AM. PM. 


AM. PM. 


AM. PM. 


AM. PM. 


G 

4 

-104° 2 


■15 


: ^ 














6 
4 

-103° 2 




Is 














8 
6 

-102° 2 


\\ 
















8 
C 
4 




\A 














-101° 2 




v- 














8 




• \ 


•A 












4 
-100° 2 






\r 












6 

4 

"99° 2 






\l 


\ 










8 
- 6 








. \ 


\ : . 


y^ 


s * - 




-98° 2 


















Pulse 
per 

min. 






I 


1 


% 


§ 


|S 


§ 


§ 


§ 


59 

OS 


CO 
OS 


®* 


to 


^ 




Resp. 
per 




g* 


s 


§ 


§ 


§ 


§ 




CO 


CO 


a 


3 


CO 

1 -i 


S3 


CO 

»1 




nun. 


































V 


Ota. 


qs. 


qs. 


qs. 


qs. 


qs. 


qs. 


qs. 


qs. 


Dcfec 


1 


II 


1 


1 


1 


1 


1 


1 



Fig. 161.— Case of Nasal Diphtheria. George P. Willard Parker 
Hospital. Injected with 3000 units of antitoxin on the 15th, and 5000 on 
the 17th. (Original.) 



symptoms do not subside, and the affection spreads, then there may be later 
a total absence of the patellar reflexes. There may also be vomiting, a 
decided apathetic condition, and a slowing of the heart's action (brady- 
cardia). 

George P., aged 7.% years, admitted to the Willard Parker Hospital Oct. 15th; 
ill two days. General condition, fair. No pseudo-membrane was visible in the 
throat. The cervical glands were very much enlarged. There was a serosanguineous 
discharge from the nose; besides, the entrance to the nostrils appeared angry and 
excoriated. Bacteriological examination showed Klebs-Loemer bacilli. Patient was 
allowed out of bed October 22d. 



PLATE XXI 

Case A. — Common Type of Diphtheria. Child three years old. Seen 
on fourth day of illness at the Willard Parker Hospital. Exudate covering 
tonsils, pharynx, and uvula. Received in all 16,000 units of antitoxin. 
Throat clear on sixth day. Case discharged cured. (Original.) 



Case B. — Follicular Type of Diphtheria. Child seven years old. 
Seen on second day of illness at the Willard Parker Hospital. The mem- 
brane involved the lacunae of the tonsils. Note the close resemblance to 
follicular tonsillitis. Received in all 6,000 units of antitoxin. (Original.) 

Case C. — Hemorrhagic Type of Diphtheria. Child seven and one- 
half years old. Seen on sixth day of illness at the Willard Parker Hospital. 
Tonsillar and post-pharyngeal exudate. Severe nasal and post-pharyngeal 
haemorrhages during exfoliation of membrane. Received in all 15,000 units 
of antitoxin. Throat clear on ninth day of illness. Myocarditis developed. 
Case discharged cured four weeks after admission. (Original.) 

Case D. — Septic Type of Diphtheria. Child eight years old. Seen 
on the fifth day of illness at the Willard Parker Hospital. The pseudo- 
membrane in this case covered the hard palate and extended in one large 
mass down the pharynx, completely hiding the tonsils. (Original.) 



PLATE XXI 



^*- JS^- 



mmf 




DIPHTHERIA. 



515 



The liver is "usually very much enlarged and feels very hard on palpa- 
tion. In other cases there will be marked diminution in the quantity of 
urine. When urine is scanty and contains casts and blood, showing a dif- 
fuse nephritis, then it is not rare to find convulsions of a ursemic character, 
resulting fatally. The sudden appearance of diarrhoea is frequently a very 
serious symptom, resulting in collapse and ending fatally. 

In other instances continuous crying may be the forerunner of earache 
resulting in suppuration. Not infrequently moist rales and bronchial 
breathing show evidences of broncho-pneumonia areas in the lungs, so that 
the general infection of a child with diphtheria should be dreaded, owing to 



1$0Z- 


JTlftfE DATES OF OBSERVATIONS 


May 


26 


27 


28 


29 


30, 


31 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


Cen t. 


Fahr. 


AK>r* 


AM"PM 


am!pm 


am:pm 


AKirfc 


AfOh' 


AMiPM 


AM-PM 


am:?m 


am:ph 


AM 


PM 


aM.'PM 


av:pm 


am:ph 


AMiPM 


am:fm 


AM!PM 


AM 


P- 


am;pm 


41° 
40°~ 


•fi 






























: is 


• V 




s 








-m-i 










^ 

^ 




















■ ^ 




a- 

ly ■ 

ft:-' 


§ 








104° -5 






























: 5> 


$ 




v>^ 








39°~ 


•6 

103 • I 










3 k 








A 














:S 




9 








102° 5 












: 


h 


A 


/ 


1 














\ 


II 








38°~ 


10]" 2 


: 


A 




;A 


A 


f 


1/ 


^ 


J. 


I 
















\ 








6 

ioo-5 


: 


^\ 




J_ 


: ^ 


4 










•\ 














V 


V 


/ 






89° -2 


3 


I 


\J 


































v/ 


37° 


;? 


z_ 










































0^~ cl 








































Pvlae 


IS 




212 


3S 


as 


3~ 


31 


3t 


OQ 0© 

32 


32 






«\| CO 

3 •* 








32 


22 


235 


Iicsptrotima 
per rnlouff 


fi 














Hn 


Vfif V) 






CO vo 


<sci*c 




MM 


vaiet 




vaoa 



Fig. 162. — Broncho-pneumonia Complicating Diphtheria. Antitoxin 
rash scarlatinal in character appeared four day? 1 after injection. Second 
eruption appeared ten days later. Note peculiarity of temperature curve. 
•Severe croup required intubation. Child remained well for thirty-two days 
Q fter second intubation, then severe croup appeared and required intubation. 
In all, seven intubations were required. Child discharged cured. (Original.) 

the danger of complications associating themselves with the primary con- 
dition. 

Follicular Forms. 

The crypts or follicles are frequently the seat of a diphtheritic infec- 
tion. Small, yellowish-white or grayish-white membranes visible as pin- 
point deposits will be seen. This variety is frequently styled lacunar 
diphtheria. 

Rashes. — Very frequently rashes follow the injection of antitoxin. 
These rashes are of an erythematous character: — 



516 THE INFECTIOUS DISEASES. 

Table No. 50. — Observations on a 8e?-ies of 350 Cases of Antitoxin Rashes at the 

Willard Parker Hospital. Site of their First Appearance, Day of Invasion 

after Initial Dose, and Persistence of Rashes. 

Erythematous rashes 109 

Punctiform 19 

Urticarial 223 

Erythematous rash on face 9 

Erythematous rash on buttocks 11 

Erythematous rash on upper extremities 18 

Erythematous rash on lower extremities 7 

Erythematous rash on body 64 

Punctiform rashes on body 18 

Punctiform rashes on upper extremities 1 

Urticarial rashes on face 18 

Urticarial rashes on buttocks 18 

Urticarial rashes on upper extremities 41 

Urticarial rashes on lower extremities 30 

Urticarial rashes on body 128 

Rashes appearing on first day 6 

Rashes appearing on second day 39 

Rashes appearing on third day 30 

Rashes appearing on fourth day 27 

Rashes appearing on fifth day . . 34 

Rashes appearing on sixth day 35 

Rashes appearing on seventh day 28 

Rashes appearing on eighth day 25 

Rashes appearing on ninth day ' . . . 14 

Rashes appearing on tenth day 12 

Rashes appearing on eleventh day 1 

Rashes appearing on twelfth day 4 

Rashes appearing on thirteenth day : 3 

Rashes appearing on fourteenth day 2 

Rashes appearing on fifteenth day 1 

Rashes appearing on sixteenth day , 2 

Rashes appearing on eighteenth day 1 

Rashes appearing on twentieth day . 1 

Rashes appearing on twenty-first day 1 

Rashes appearing on twenty-seventh day 1 

Persistence of Antitoxin Rashes. 

Rashes lasting one day 17 

Rashes lasting two days 174 

Rashes lasting three days -. 55 

Rashes lasting four days 3 

Rashes lasting five days 6 

Rashes lasting six days 2 

Rashes lasting eight days : 1 

Rashes lasting nine days 1 



PLATE XXII 




Lizzie F., 5 years old, was admitted to the Willard Parker Hospital in 
September. 1904. She was ill seven days before admission. Diphtheria was 
present on both tonsils. There was slight glandular swelling. The general 
systemic condition was poor. The temperature was 101° F., pulse 126, 
respiration 24. The child received 5000 units of antitoxin on admission, 
and on the following day a ^econd injection of 4000 units. Four days after 
the second injection of antitoxin, the throat cleared so that no membrane 
was visible. Two days later, or six days after the second antitoxin injec- 
tion, a universal rash appeared on the face, chest, abdomen, back, and ex- 
tremities. This rash was morbilliform in character and persisted for 
twenty-two days, although it was chiefly confined to the arms and legs. Xo 
complications followed. The child left the hospital in excellent condition. 
(Original.) 



DIPHTHERIA. 517 

C. Hartung quotes a number of European observers, who found an 
antitoxin rash in 11.4 per cent of 2661 cases. Berg found that rash 
in 82 cases out of 337, or 24 per cent. This condition is described in detail 
in Nothnagel's Encyclopaedia, pages 153-162. 

While Northrup reports 147 cases of rash occurring between the seventh 
and twelfth day, other observers report the rash as occurring much earlier. 
In the series above reported the largest number of rashes occurred on the 
second and third day after the injection. I have frequently seen an anti- 
toxin rash several hours after the injection was given, while the majority 
of rashes were fully developed on the second day. 

The following case illustrates the rapidity with which a rash may 
appear : — ■ 

Laurence S., aged 4 years. Admitted September 8, 1903, to the Willard 
Parker Hospital, on the third day of illness. He was in a poor condition when 
admitted. He was intubated about one-half hour before being admitted to the 
hospital. Slight retraction present. Membranes on right tonsil. Profuse nasal 
discharge. 

The physical examination was negative. The heart regular and of good force; 
4000 units of antitoxin, of serum (horse) 220, were given when admitted. There 
was no rash present when the antitoxin was injected. Seven minutes after the anti- 
toxin injection the patient had a profuse rash all over the chest, extending from 
the fifth ribs to clavicles. The rash and flush were most marked in the area cor- 
responding to the place of injection. The tongue was heavily coated. Could not 
take much nourishment. Grew gradually worse. Died September 9th. 

Site of the Eruption. — A large flush is frequently seen on the parts 
around the point of injection, from whence it spreads over the body. It is 
most frequently seen, however, on the abdomen, chest, and buttocks. The 
face and neck are seldom involved. There is itching and occasionally the 
children complain of intense pain in the joints. Fever usually precedes 
the eruption. 

Constitutional symptoms, such as vomiting, diarrhoea, headache, mus- 
cular pains, and general malaise, are noted. Not infrequently when hyper- 
pyrexia exists there is delirium or convulsions (Sevestre and Martin). 

In urticaria and other serum rashes both the itching and rash will 
disappear in twenty minutes to one-half hour after one subcutaneous injec- 
tion of ten minims of 1 to 1000 adrenalin solution. 

Anaphylaxis. 

When we inject the first dose of horse serum we sensitize the guinea 
pig or rabbit, and the serum which was innocuous to, the animal before the 
first injection was given has now made the animal so hypersensitive that 
the second injection of the same serum is not only very poisonous, but may ■ 
result fatally. Such sensitive reaction when found in human beings is 
called anaphylaxis. 



518 THE INFECTIOUS DISEASES. 

Richet demonstrated the fact that, although an animal could be sensi- 
tized to an injection of a non-toxic dose of serum, a second injection 
of a minimal quantity after a certain interval proved fatal. Later Arthus, 
using horse serum, obtained similar phenomena. Yon Pirquet and Schick, 
working along similar lines, first definitely classified the symptom complex 
which develops after the injection of therapeutic sera as serum disease. 
They interpreted this as a reaction to a specific foreign protein. Briefly, 
the symptoms are as follows: Various skin manifestations of urticarial or 
erythema multiforme type, fever, oedema, and pain in the joints. They 
occur usually after a definite period of incubation of eight to twelve days. 

When such individuals are re-injected the incubation period is reduced 
to a few hours. A local reaction, called the Arthus phenomenon, is present 
at the point of injection. The general symptoms are of short duration and 
sometimes accompanied by collapse. For this clinical picture von Pirquet 
has coined the word "allergy." The sensitizing substance itself has been 
named allergen, which from the findings of Eosenau and Anderson is identi- 
cal with the toxic substance of serum. It has been shown that the anaphy- 
lactic reaction is a specific one, e.g., guinea pigs sensitized with horse serum 
do not react against other albuminous bodies, such as egg albumin or milk. 
It has been demonstrated that acquired susceptibility can be transmitted 
by heredity. 

Mcolle and Otto have shown that a condition of passive anaphylaxis 
could be induced by treating a normal animal with the serum of an anaphy- 
lacticized animal. Although in animal experimentation in the vast majority 
of instances results are obtained by injection, Eosenau and* Anderson suc- 
ceeded by feeding animals in obtaining the reaction by way of the 
alimentary canal. 

Wolff-Eisner believes that the phenomena of anaphylaxis are of central 
origin, so that individuals with an unstable vasomotor system are especially 
predisposed to the more severe forms of hypersensitiveness. Thus, asthma, 
urticaria, fibrinous bronchitis, and membranous enteritis are all related in 
their symptomatology. He alludes to vasomotor irritability, which causes 
eosinophile secretions, the fibrinous exudate, and the spastic condition as 
well. That there may be some relationship between the anaphylactic condi- 
tion and a disturbance of the internal secretions has been discussed recently 
by Hoffmann. He argues because urticaria and hay fever or asthma are 
frequently associated in hyperthyroidism therefore the glands of internal 
secretion must influence the vessel-tone by their products, giving rise to 
anaphylactic manifestations. 

The Prevention of Anaphylactic Shock. — According to Bedreska, if the 
serum to be injected is heated to 56° C, or 133° F., then not only can the 
phenomena be diminished, but, as a rule, averted. 

According to Vaughn, if a preliminary injection of as little as 0.1 or 



DIPHTHERIA. 519 

0.2 c.c. of serum should be made and no serious symptoms follow within 
two hours, the full dose can then be given. 

Asthmatics are very sensitive. A hypodermic injection of atropine will 
be useful to prevent anaphylactic shock in a patient supposed to be unduly 
sensitive to the phenomena of anaphylaxis. 

Desquamation. — A very tine, mealy desquamation follows the anti- 
toxin rash. It is similar to the measles desquamation (Berg). A rash re- 
sembling measles never has the catarrhal symptoms which we always note 
in genuine measles. If, however, we are in doubt regarding the true nature 
of the rash, it is well to isolate and await results rather than to expose 
children to the risk of infection. 

Diagnosis. — The diagnosis of diphtheria affecting the pharynx, ton- 
sils, and nares with visible membranes is quite easily made. When, how- 
ever, the disease affects the lower respiratory tract, the larynx, trachea, or 
bronchi, the diagnosis will be rendered more difficult. The crucial test con- 
sists in taking a culture and noting the bacteriological result. The presence 
of the Klebs-Loeffler bacillus means diphtheria, especially if the glands of 
the neck are swollen. 

We must not infer that if the Klebs-Loeffler bacillus is not found 
our case is of a non-diphtheritic character. A technical error, such as 
swabbing a healthy surface instead of an infected area, may be the cause of 
a negative result. Not infrequently in the most malignant forms of diph- 
theria, nothing but a streptococcus can be found. This is especially true 
when complications such as broncho-pneumonia are met with. 

Bacteriological Diagnosis. — Directions for Inoculating Culture Tubes 
with the Exudate in Cases of Suspected Diphtheria: The child should be 
placed in a good light, and properly held. Eemove the swab from its tube. 
Depress the tongue with a spoon in the left hand. With the swab in the 
right hand rub firmly but gently against any visible membrane on the ton- 
sils or in the pharynx. Withdraw the cotton plug from the culture tube. 
Insert the swab, and rub it thoroughly but gently back and forth over the 
entire surface of the blood serum. Do not allow the swab to touch any- 
thing except the throat of the patient and the surface of the serum. Do 
not push the swab into the serum or break the surface in any way. Ee- 
place the swab in its own tube; plug both tubes; fill out the blank forms 
which accompany each tube, and send to a culture station. 1 

Out of 1857 cases of diphtheria admitted to the Willard Parker Hos- 
pital during 1910, 426 showed negative cultures on admission, and 1431 
showed positive cultures on admission. The total number of croup cases 
admitted was 403. 

1 The New York Department of Health has a series of culture stations in 
various drug stores. At these stations sterile culture tubes are supplied to the 
physician and the same are also collected daily after inoculation. The Depart- 
ment of Health furnishes material, including examination and report, free of charge. 



520 ™ E INFECTIOUS DISEASES. 

533 cases showed tonsillar exudate. 
348 cases showed laryngeal exudate. 
160 cases showed tonsillar and pharyngeal exudate. 

39 cases showed tonsillar, pharyngeal, and nasal exudate. 

36 cases showed pharyngeal exudate. 

23 cases showed nasal exudate. 

The Schick Reaction. 1 — The use of the Schick reaction, as well as its 
practical application, has been popularized by Dr. A. Zingher, of the New 
York Health Department Kesearch Laboratory. In a person susceptible to 
diphtheria, the blood does not contain antitoxin, and the toxin used for 
testing produces a reaction. This reaction is visible within twenty-four to 
thirty-six hours after such test is made. It remains three or four days, is 
of a pinkish or reddish color, and at the end of one week fades into a 
bronze color, which may remain visible two weeks or even longer. 

It has been found that 85 per cent, of infants within the first year are 
negative with this test. Between the second and fifth years., however, 35 
per cent, of children are immune, 5 per cent, being susceptible. Between 
the fifth and tenth years 75 per cent, are immune. 

The Schick test can also be used to differentiate true diphtheria from 
other membranous exudates. If a negative reaction occurs, it shows the 
presence of sufficient antitoxin in the blood, hence a diagnosis of diphtheria 
should not be made. 

Antitoxin given intramuscularly before or simultaneously with the 
toxin usually completely inhibits the Schick reaction. 

The technique of the method is as follows : After an area of skin on 
the forearm has been cleansed with alcohol, the latter is encircled with the 
thumb and index finger, and the skin held tense between them. 2 The 
needle is dipped into the bottle of pure, undiluted diphtheria toxin and 
immediately inserted intradermally and not subcutaneously. The needle is 
an ordinary hypodermic bent at a distance of one-fourth inch from its point 
so as to make an angle of about 170 degrees. The angle aids in inserting 
the needle intradermally. 

The toxin used by Schick and his associates 3 is a dilution of such 
strength that 0.1 cubic centimeter equals % of the lethal dose for a 250 
Gm. guinea-pig. The lethal dose of the toxin which Schick uses is 0.005, 
and hence he injects 0.1 c.c. of a 1 : 1000 dilution. In those who react an 
area of reddening and infiltration develops within twenty-four hours, reach- 
ing its maximum in forty-eight hours, and which heals with scaling and a 
characteristic central pigmentation. Although the reaction is similar to the 
local tuberculin reaction, its interpretation is directly opposite. The 



x Park, Zingher, and Serota, Jour. Amer. Med. Assoc, September 5, 1914. 
•Koplik and Unger, Jour. Amer. Med. Assoc, April 15, 1916. 
3 Veeder, Amer. Jour, of Dis. of Children, August, 1914. 



PLATE XXIII 





A — Shows four tpyical positive Schick reactions of varying degrees of intensity 
forty-eight hours after test, a is a strongly positive reaction, with vesieulation of 
the surface layers of the epithelium, which is seen occasionally in individuals who 
have practically no antitoxin; 6 and c are positive reactions; d, a moderately 
positive reaction. 



B 




B — Shows a fading positive Schick reaction one to four weeks after test in 
various stages of scaling and pigmentation, a shows redness, scaling and beginning 
pigmentation after one week: b and c, pigmentation after two and three weeks; 
d. faint pigmentation after four weeks. (After Park and Zingher, Amer. Jour. Dis. 
Children, April, 1916.) 



PLATE XXIY 




Shows two pseudoreaetions forty-eight hours after test, and a combined reaction. 
a, mild; b, marked; c, a combined positive and pseudoreaction. (After Park and 
Zingher.) 



DIPHTHERIA. 



521 



diphtheria toxin is a direct toxic agent and by control tests of- the blood- 
serum it has been found that a negative reaction is always associated with 
the presence of diphtheria antitoxin in the blood of the person tested. 
While, as a rule, a positive skin reaction is an indication of the absence 
of antibodies, some persons react positively for some unexplained reason 
who possess a greater amount of antitoxin in the blood than 0.03 units per 
cubic centimeter. 

It has been found that if a negative reaction follows the injection of 
a 0.1 cubic centimeter of a 1 : 1000 dilution of toxin, the individual tested 
has at least 0.031 units of antitoxin per cubic centimeter in his blood when 




Fig. 163. — Pneumonia Complicating Diphtheria. (Kind assistance of 
Dr. Edward H. Sparkman, Jr., at the Willard Parker Hospital.) A. 
Starting point of pneumonia, showing extent on third day. B. Focus 
which developed three days after A, showing extent on third day of the 
new focus. (Original.) 

tested by Epmer's method. A person with a higher concentration of anti- 
toxin will react negatively to a smaller dilution of antitoxin and vice versa. 
Thus the outcome and the degree of reaction are dependent on two factors — ■ 
the strength of the toxin used and the presence of antitoxin in the blood. 

As there is no antitoxin present in the blood in acute diphtheria, the 
use of the reaction for diagnostic purposes has been suggested. Thus in a 
suspected case or questionable diagnosis a negative reaction — indicating the 
presence of antitoxin, would speak against the diagnosis of diphtheria. 

Differential Diagnosis. — In the very beginning of the disease, before 
the appearance of a pseudo-membrane, the diagnosis is beset with difficulty. 
Thus, an acute catarrhal angina will show symptoms similar to those of 
diphtheria. 

Pre-membranous Diphtheria. — When a child has been exposed to diph- 
theria, the careful daily inspection of the nose and throat is demanded. At 



522 ™E INFECTIOUS DISEASES. 

the slightest rise of temperature associated with an intense congestion of 
the pharynx and tonsils, antitoxin should be injected. 

The diagnosis of diphtheria can usually be made twenty-four to forty- 
eight hours before the membranes are visible. A culture should always be 
taken, but too much reliance must not be placed on the bacteriological 
findings, because the Klebs-Loefner bacillus may have invaded the deeper 
structures and not be present on the surface; therefore, cultures should be 
taken daily until the disease can positively be excluded. The cervical glands 
are usually swollen. 

Thrush sometimes resembles diphtheria, but can be differentiated by 
the fact that the small, whitish spots resembling curdled milk are scattered 
over the cheeks, lips, tongue, and gums, in addition to the uvula and 
pharynx. 

Ulcerative tonsillitis 1 resembling diphtheria has been described by Vin 
cent. In this condition there is no tendency to spread. There is an absence 
of croup, and a culture taken shows the Vincent bacillus instead of the 
Klebs-Loefner bacillus. 

Peritonsillar Abscess. — In this condition we meet with a swelling or 
bulging forward of the affected parts. The uvula is sometimes displaced. 
There are very many active local symptoms, such as pain and difficulty 
in swallowing, and a nasal tone of voice. Not infrequently when an at- 
tempt to swallow is made the fluid regurgitates through the nose. When 
children are old enough to describe subjective symptoms, they will complain 
of chills and fever. The temperature is usually high, ranging from 102° to 
105° F. The active symptoms subside the moment pus is relieved. Nature 
frequently gives a spontaneous evacuation of the pus. At other times it is 
wiser to give relief by making an incision and emptying the pus. A culture 
taken in this condition does not show the presence of the Klebs-Loeffler 
bacillus. 

Follicular Tonsillitis. — In this condition more than in any other form 
of disease we must be careful regarding a positive opinion. There are 
follicular forms of diphtheria involving the lacuna of the tonsils which 
clinically so resemble diphtheria that even an expert cannot differentiate 
them. 

Table No. 51. — Complications Observed at the Willard Parker Hospital. 

1910 1911 

Number of Cases 1857 1558 

Eye Complications. 

Conjunctivitis ( Catarrhal) 105 51 

Conjunctivitis (Diphtheritic) 7 3 



"Read article on "Tonsillitis." 



DIPHTHERIA. 523 



Ear Complications. 



Mastoiditis (Operative) 2 

Otitis Media 135 112 

Nasal Complications. 
Paralysis 8 13 

Throat Complications. 

Paralysis (Pharyngeal) 112 28 

Peritonsillar Abscess 14 9 

Cervical Adenitis 318 101 

Pulmonary Complications. 

Broncho-pneumonia 334 201 

Lobar Pneumonia 6 5 

Empyema 5 2 

Cardiac Complications. 

Pericarditis 2 2 

Myocarditis 110 100 

Endocarditis . 40 

General Complications. 

Nephritis - 20 30 

Delirium 31 10 

Vaginitis 110 129 

Arthritis 5 6 

Convulsions 5 5 

Syphilis . 4 

The clinical manifestations of the benign form of follicular tonsillitis 
have already been described in the article on "Follicular Tonsillitis." 

The differential diagnosis depends on the presence or absence of the 
Klebs-Loeffler bacillus. 

Complications. 1 — The most frequent complication met with is broncho- 
pneumonia. More deaths occur from this than from any other complica- 
tion. It is usually the extension of the disease from the larynx to the 
bronchi. When a septic form of diphtheria exists broncho-pneumonia usu- 
ally accompanies it. (See chapter on "Pneumonia.") 

Pleurisy with serous effusion frequently complicates this disease. 

Empyema not infrequently complicates. A number of these cases have 
been seen by me during my service at the Willard Parker Hospital. 

Otitis is occasionally met with as a complication of diphtheria. It is 
usually the result of a streptococcus infection through the nose or throat 
into the Eustachian tube. 

Myocarditis is the most frequent form of heart complication met with 
in diphtheria. 

Endocarditis and pericarditis are also seen in severe types of this 
disease. 



1 For a detailed description of the various complications, the reader is re- 
ferred to the special articles on "Otitis," "Empyema," etc. 



524 



THE INFECTIOUS DISEASES. 



Meningitis is not often seen, though I have seen 3 such cases out of 
a total of 35 at the Willard Parker Hospital during my service. About 
10 per cent, of all septic cases have meningitis. 

Cerebral thrombosis and embolism occasionally complicate diphtheria, 
and result in hemiplegia, convulsions, or aphasia. 

Thrombosis of the pulmonary artery of the heart may cause sudden 
death. This is usually accompanied by feeble heart's action the result of 
degenerative changes in the muscular walls (Holt). 



1903- 


DATES OF OBSERVATIONS. 




6 


7 


8 


9 


10 


11 


12 


J3 


14 


15 


Cent. 


Fahr. 


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AfOM 


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3 



Fig. 164. — Temperature Chart from a Case of Diphtheria complicated by 
Broncho-pneumonia (Step-ladder Type of Fever). (Original.) 

Hemorrhages occur quite often. Bleeding from the nose and from the 
ear, also blood in the urine and blood in the stools, has frequently been seen 
by me. These cases are of the most severe type and usually end fatally. 

When the hemorrhagic type is seen early, and the toxin in the circula- 
tion rapidly neutralized by the intravenous injection of antitoxin, the 
chances of recovery are greatly increased. 

Purpuric spots similar to that form of purpura met with in rheumatism 
were seen by me in septic cases, all of which ended fatally. 

Acute Renal Congestion. — This usually accompanies severe diphtheria. 
In many instances it is a forerunner of an acute nephritis. The earliest 



DIPHTHERIA. 



525 



symptoms noted are albumin and red blood cells. At times the urine may be 
scanty. The toxin filtering through the system attacks .the kidneys as well 
as the heart, and it is important to make daily examinations of the urine, 
so that nephritis, if present, can readily be detected. 

The action of the kidneys during diphtheria is as important as the 
action of the bowels, because the retention of toxin may result fatally. 

If the urine is scanty the temperature will be higher, and, therefore, a 
mild diuretic, such as 5 to 10 grains of citrate of potassium, is indicated. 



ifLQS... 


DATES OF OBSERVATIONS" 




1 


2 


3 


4 


5 


6 


7 


8 


9 


10 1 Hi 


Cent. 


Fakr. 


AM>M 


ak:pm 


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51 



Fig. 165. — Temperature Chart from a Case of Diphtheria complicated by 
Lobar Pneumonia. (Original.) 

The application of a warm-water bag over the kidneys also stimulates 
diuresis. Dry cupping over the kidneys repeated every twelve hours will 
stimulate the now of urine. Moderate quantities of water should be given 
to flush the kidneys and eliminate toxin. 

Nephritis 1 is usually met with in septic cases, although it may follow 
as a complication of the milder form of this disease. Traces of albumin 
are frequently found during the course of diphtheria. This does not 
necessarily imply that we are dealing with nephritis. The presence of casts, 
in addition to the albumin, or possibly blood, is necessary to strengthen the 
diagnosis of nephritis. 



x An excellent illustration of nephritis complicating diphtheria is described in 
the article on "Nephritis." 



526 



THE INFECTIOUS DISEASES. 



Diarrhcea due to a follicular ileo-colitis or acute gastric catarrh fre- 
quently complicates diphtheria. 

Diarrhoea, when present, is nature's method of eliminating toxins and 
should be looked upon as an aid in cleansing the system rather than as a 
complication. When diarrhoea is not present and the bowels are constipated, 
then sufficient hydragogue cathartics, such as calomel or compound jalap 
powder, should be prescribed to produce loose bowels. 

Diphtheritic Gastritis. — When membranous gastritis occurs it is usu- 
ally a diphtheritic gastritis. 

Diphtheritic omphalitis is described in Chapter III, Part II. 

When membranous enteritis complicates diphtheria it is usually the 
result of a streptococcus or Klebs-Loemer infection. 



I9-Q3- 




JJususi 


4 


5 


6 


7 


8 


9 


10 


Cent. 


Fakr. 


AM>M 


am:pm 


AMiPM 


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Fig. 166. — Temperature Chart from a Case of Diphtheria complicated by 
Otitis and Meningitis. Fatal. (Original.) 

Profound anaemia usually follows diphtheria. This is due to the effect 
fif the toxins in the blood causing the destruction of the red corpuscles. 

Post-diphtheritic Paralysis. — Toxaemia caused by absorption of the 
toxins generated by the Klebs-iLoeffler bacillus, if not neutralized either by 
an injection of antitoxin or by Nature's own production of antitoxin, fre- 
quently causes paralysis. This paralysis usually affects individual muscles 
or groups of muscles. In this manner the heart, which is a muscular organ, 
is frequently paralyzed, resulting in death. When the toxin affects the 
respiratory centers it may result in paralysis, causing death by asphyxia. In 
addition to the paralytic effect of thisi toxin on the muscles and nerves, 
degenerative changes are brought about by the influence of this poison. 
Thus it is that the toxin in the system will frequently irritate an otherwise 
healthy kidney and set up a toxic nephritis. 



DIPHTHERIA. 527 

From the foregoing we can see that the poison generated by the Klebs- 
Loeffler bacillus is certainly a serious factor which must be dealt with very 
energetically. 

A study of recorded cases of paralysis shows that between 10 and 30 
per cent, of all cases of diphtheria are followed by paralysis. Woodward 
studied 7832 cases of diphtheria; of these 1362 had post-diphtheritic paral- 
ysis. Myers, in the London Lancet, 1900, studied 1316 cases of the disease, 
in which 275 cases, or about 21 per cent,, had palsy. 
110 cases affected the palate, 
69 cases were cardiac, 
21 cases diaphragmatic. 

There are four palsies due to severe toxaemia ; they occur in the follow- 
ing order : palatal, ocular, cardiac, and diaphragmatic. 

Paralysis is most frequently found in children between the second and 
sixth years. Usually during the second week following diphtheria, when 
the child is convalescent, emaciation of the extremities will be noticed. If 
the muscles of the trunk are involved, there will be emaciation of the thoracic 
muscles, regurgitation of liquids through the nose, and a nasal twang in 
the voice. There is marked difficulty in walking or climbing stairs in other 
cases; the child waddles and appears weak, falls easily, and staggers as in 
ataxia. In severe cases the child is unable to raise its head. The sphincter 
of the rectum and bladder may become paralyzed, resulting in involuntary 
urination or obstinate constipation. 

Paralysis of the extremities may be added to paralysis of the respira- 
tory muscles or of the heart. The knee-jerk may be diminished or absent. 
The absence of the knee-jerk indicates some change in the peripheral neu- 
ron. The special heart symptoms indicating cardiac paralysis are irregu- 
larity of heart's action or a gallop rhythm, bradycardia, tachycardia, lower- 
ing of the temperature (usually subnormal), vomiting; dilatation of the 
heart, a short first sound with systolic murmur at apex, blueness of the lips, 
and -cold extremities. 

"Monicatide divided diphtheritic paralysis into four groups: Those 
showing (1) purely muscular change without nerve involvement; (2) 
polyneuritis; (3) lesions of the spinal cord, which were either localized in 
the gray matter, leading to atrophy of muscles, or involved the white matter 
of the cord in a similar way to that seen in locomotor ataxia or multiple 
sclerosis, and (4) cerebral haemorrhage chiefly due to circulatory change. 
This classification is accepted by many of to-day. To be scientifically cor- 
rect, however, the fourth group, i.e. L , the cerebral palsies, should not be 
classed as a palsy due to a diphtheritic toxin, inasmuch as they are acci- 
dental. Strictly speaking, the term diphtheritic palsy should be applied to 
those palsies only which are due to direct action of the diphtheritic toxin." 

A child, 4 years old, was seen durjng my service at the Willard Parker Hos- 
pital. He had suffered with severe tonsillar and pharyngeal diphtheria. The 
exudate was unusually thick. The resident physician called my attention to a 



528 THE INFECTIOUS DISEASES. 

regurgitation of the liquids through the nose and to the nasal twang in speaking. 
On examining the throat, all evidences of diphtheria had disappeared. The tip of 
the uvula, instead of hanging in the median line, pointed toward the left side. As 
this case was a severe type of diphtheria we were not surprised to see the paralysis. 
Strychnine was given. The case recovered. 

When diphtheria has preceded an attack of paralysis., the diagnosis 
is easily made. Emaciation is general, as a rule, and not confined to a 
simple group of muscles. 

The disease is sometimes mistaken for acute anterior poliomyelitis. 
The onset of the latter is sudden, and is usually preceded by fever. The 
absence of a history of diphtheria aids in establishing the diagnosis. 

In 275 cases reported by Myers, 80 died, or 29' per cent. 

Course. — A mild case of diphtheria will show exfoliation of the exudate 
on the tonsils and pharynx about twenty-four to forty-eight hours after a 
sufficient dose of antitoxin has been injected. In four or five days after the 
beginning of illness, the disease usually disappears, so that there is no 
visible evidence of the same. 

In a severe case 1 (male, 8 years old) seen by me in October, 1904, in the wards 
of the Willard Parker Hospital, the exudate completely covered the fauces. The 
tonsils, uvula, and pharynx were covered with one large mass of pseudo-membranes. 
The cervical glands were very much enlarged. The case looked decidedly septic. 
An injection of 5000 units of antitoxin was given on the first day, soon after ad- 
mission to the hospital. A second injection of 5000 units was given on the second 
day. A third injection of 5000 units was given on the third day. A fourth 
injection of 5000 units was given on the fourth day, so that 20,000 units were admin- 
istered during the first four days after admission to the hospital. The membrane 
exfoliated, the swelling of the glands disappeared and, one week after his admission, 
the throat was clear and he was convalescent. 2 

A mild case of diphtheria may last from five to eight days. Severe 
types may last many weeks. No case of diphtheria should be considered 
to have run its course until the heart's action is normal and the general 
condition good. Sudden death may come from over-exciting a weakened 
or damaged heart if proper caution is! not used. 

Prognosis. — The uncertainty of this disease and the ease with which 
complications follow must be taken into consideration in giving the prog- 
nosis in a given case of diphtheria. A child suffering from diphtheria, 
who was brought up in unsanitary surroundings or one deprived of breast- 
milk, will suffer much more than one favored with the opposite conditions. 
Such factors are important in giving an opinion. A child with rickets is 
more liable to succumb to an infection from diphtheria and may possibly 



1 The colored illustration D, Plate XXI, was drawn from this case at the bed- 
side in the Willard Parker Hospital. 

2 This case was reported by me at a meeting of the New York State Medical 
Association held October 19, 1904. 



DIPHTHERIA. 529 

die, when a child with a strong normal body and healthy internal organs 
will recover. In this disease we therefore note that it is the "survival of 
the fittest." When diphtheria follows typhoid, or when it is a complica- 
tion of a severe systemic infection, like scarlet fever, then great care should 
be exercised in venturing an opinion as to the probable outcome of the 
attack. 

The guide in estimating the prognosis of any case of diphtheria should 
always be the condition of the heart. A very ra.pid pulse or a gradually 
increasing pulse-rate are bad signs. The temperature cannot be looked 
upon as the most impotent factor in determining the outcome of this con- 
dition. I have seen cases of diphtheria in hospital as well as in private 
practice where normal temperatures prevailed and still septic conditions 
were positive. Such cases, showing a low inflammatory, type having slight 
elevations of temperature, rarely recover. The prognosis is also influenced 
by the time at which the treatment was commenced. When antitoxin is 
injected on the first or second day of the disease the outcome is brighter 
naturally than when the disease extends without specific treatment. The 
mortality is greatest in children under 2 years of age. 

Prophylaxis. — In no disease should we be more careful than in diph- 
theria. Strict isolation of all cases should be enforced, so that no trans- 
mission of the disease can take place. 

In New York City children suffering from diphtheria are excluded 
from school for a minimum period of one week and must not be readmitted 
until all symptoms have disappeared and the culture is negative. If quaran- 
tine is observed, children and others who have been immunized against the 
disease, and cultures from whose throats do not show diphtheria bacilli, may 
return to school. If children or others in the family are immediately re- 
moved to another address and culture taken from nose and throat is 
negative, they may be readmitted. If continuing to reside at home and the 
above precautions are not taken, they cannot be readmitted until the case 
has been officially discharged. 

Visitors may be permitted in a room where diphtheria exists, providing 
they do not come into direct contact with the patient. 

The vital point to be considered is how to prevent complications. The 
question arises: Can complications be prevented by proper treatment? 
They certainly can if treatment is commenced early in the disease. We 
must carefully watch all the functions of the body and stimulate those that 
do not seem to act. The emunctories are the most important which require 
watching. If the kidneys are found secreting very small quantities of urine, 
then we can be reasonably sure that the toxins stored in the kidneys will 
cause serious damage. When therefore a scanty secretion of urine is met 
with it will at once call for active diuretic treatment. The rule I have 
always followed is to stimulate with mild diuretic treatment from the be- 

34 



530 THE INFECTIOUS DISEASES. 

ginning, and secure a copious secretion of urine. The same is true regard- 
ing the condition of the bowels. In no disease is it as important to have 
food assimilated and to have proper evacuation as" in the course of the 
treatment of diphtheria. 

We eliminate large quantities of toxins by the bowel, ' the skin, and 
the kidneys ; hence we have it in our means to hasten recovery and- at the 
same time guard against storing up poison in the blood. 

The clothing should be warm. The child should not be exposed while 
bathing. We must guard against draught's, as we know there is a peculiar 
predilection for pneumonia in the course of diphtheria. The urine must 
frequently be examined. The examination must not only be chemical, 
but microscopical. The moment we find our case complicated by nephritis, 
the same should be given proper attention. 

Isolation. — Very frequently children have Klebs-Loefner bacilli in the 
throat — -so-called culture cases — in the premembranous stage of the dis- 
ease. Some of these develop diphtheria of the most virulent type. A safe 
rule, therefore, is to insist on the isolation of every child having the Klebs- 
Loeffler bacillus in the secretions of the nose and throat, for weeks and 
months if necessary, until a swab from the throat shows an absence of the 
Klebs-Loeffler bacillus, to guard against possible development of fatal diph- 
theria. 

The finding of diphtheria bacilli in the throat without marked clinical 
indications of diphtheria has no significance, according to Behring. 1 

He asserts that about 10 per cent, of the entire population carry diph- 
theria bacilli in their throats without resulting infection. The bacilli have 
lost their virulence, or else the individual possesses a natural immunity. 
He considers all bacteria with the morphological characteristics of Loeffler's 
bacillus true diptheria bacilli, but he would differentiate a simple angina, 
rhinitis, or conjunctivitis from diphtheria, even with diphtheria bacilli 
numerous in the organ involved, if there were no general symptoms of 
diphtheria. He affirms that it is useless and nonsensical to isolate persons 
who have been exposed to diphtheria. It is impossible to free people from 
the bacilli or to keep them permanently free. Infection results from a pre- 
disposition, which is in turn due to a lack of antitoxic serum in the blood. 
The antibodies which undoubtedly exist in the blood of numerous indi- 
viduals are probably produced by the vital activity of avirulent diphtheria 
bacilli in their throats. He consequently suggests that it might be possible 
to induce auto-immunization by transplanting avirulent diphtheria bacilli 
into the throats of other human beings. The comparative immunity of 
physicians to diphtheria may be due to the repeated, unconscious inocula- 
tion with small doses of the virus. Extensive, systematic preventive inocu- 



1 Therapie der Gegenwart (Berlin), 



DIPHTHERIA. 531 

lation with antitoxin would induce a natural immunity to the disease and 
entail the final disappearance of diphtheria. 

While the view maintained by Behring is interesting, it certainly does 
not conform to modern clinical experience. No child should be permitted 
at large with diphtheria bacilli, owing to the possible fatal result entailed 
thereby. 

Immunization in Diphtheria. — Immunity in the Nursling: There 
seems to be an immunity conferred upon the nursling. This may be due 
to the antitoxic properties of serum contained in the mothers milk. 

Diphtheria rarely attacks nurslings, but most frequently attacks infants 
brought up by hand-feeding — the bottle babies. It is most frequently met 
with between the second and eighth years. The disease may recur and has 
been known to attack patients three or four and even more times. 

How to Immunize. — When a case of diphtheria occurs in a family in 
which there are apparently very healthy children, then immunity can be 
conferred upon them by giving an injection of antitoxin. This immunity 
is in the nature of prophylactic treatment. The average dose required for 
a child from 1 to 5 years is 500 to 1000 units. For older children, from 
5 to 12 years, 1000 antitoxin units may be injected. No further treat- 
ment will be necessary after the injection. All aseptic precautions which 
are described in the article on the "Injection of Antitoxin" must be used 
whether we inject a large or a small dose of antitoxin. It must not be sup- 
posed that because an immunizing dose- of antitoxin has-been injected 
such a child may then be exposed to this disease with impunity. Experi- 
ence has shown that when children have been given an immunizing dose 
of antitoxin and are immediately isolated, as a rule they do not take the 
disease. On the other hand, if children are permitted to remain in the 
same room with a case of malignant diphtheria^ it is quite plausible to 
assume that they will take the disease, even though an immunizing dose 
of serum has been injected. Immunity is usually conferred for a period 
of two or three weeks. It is a good plan to repeat this same immunizing 
dose of antitoxin if diphtheria still prevails in the household three weeks 
after the first injection has been given. Children receiving an immunizing 
dose should be treated as though they were perfectly well children. There 
should be no restriction to their diet and they should be permitted to romp 
and play in the open air, and receive their bath just as though no injection 
had been given. 

The New York Board of Health reported a series of immunizing in- 
jections in 6806 individuals, given by their inspectors from January 1, 
1895, to January 1, 1900. Out of the above number, 18 contracted diph- 
theria of a mild type; 1 contracted diphtheria complicated with scarlet 
fever; total, 19 cases, the last case of scarlet fever ending fatally. The 
New York Board of Health, Division of Bacteriology, from January, 1898, 



532 THE INFECTIOUS DISEASES. 

to January, 1900, reports 682 cases of diphtheria which were secondary to an 
original case in the same family. Under secondary are included only those 
cases which occurred at least twenty-four hours after and within thirty 
days of the primary case. Of these 682 cases, 61 died, a mortality of 8.9 
per cent. Had these 682 cases received antitoxin (immunizing dose) when 
the physician first visited the families, probably not one of them would 
have contracted the disease. When immunity is conferred by an injection 
of antitoxin it lasts about twenty days, provided it is given twenty-four 
hours previous to actual exposure. 

As a rule no harm will result by the injection provided the serum used 
is of a standard quality. We must not expect to prevent follicular tonsil- 
litis or any other disease by an immunizing injection of antitoxin. 

Morrill reports that of 1808 children immunized at least every twenty- 
eight days with 150 to 500 units of serum, 7 had diphtheria : 3 from in- 
sufficient dosing, 2 within twenty-four hours of the injection, and 2 in 
twenty-two and twenty-three days. Of 829 who had not been given anti- 
toxin, or in whom more than twenty-eight days elapsed after the injection, 
9 had diphtheria, besides 3 immunized adults. 

Biggs and Guerard, from 35 reports of 17,516 cases in which small 
doses of antitoxin were given as an immunizing agent, state that diphtheria 
occurred in 131 cases: 109 mild cases and 1 fatal case within thirty days 
of the date of injection ; 20 mild cases and 1 fatal case after thirty days. 

At the New York Infant Asylum 107 cases of diphtheria occurred 
between September and January, 1895 (30 cases a month). In October 
bacteriologic examination showed diphtheria bacilli in almost one-half of 
the throats. 

January 16th 224 children were given immunizing doses of antitoxin, 
and up to February 15th only 1 case of diphtheria occurred. A second case 
then developed and between February 15th and 27th, 5 cases. On the 25th 
245 children received antitoxin, and no cases occurred for thirty-one days. 
To sum up: before isolation and immunization 107 cases occurred in one 
hundred and eight days; after the latter was practiced, 5 cases in one 
hundred and twelve days. 

The occurrence of diphtheria during an epidemic of measles at the 
New York Foundling Hospital added greatly to the mortality of the dis- 
ease. During an epidemic of measles at that institution every child was 
given 400 units of antitoxin. The result was most encouraging, as is shown 
by the immunity conferred by the injection. 

In 149 cases of measles, 500 units of diphtheria antitoxin were given at 
the first appearance of measles symptoms. No cases of diphtheria secondary 
to measles occurred in any of those cases for a period of one month at least. 
Since the appearance of the latter report another epidemic of measles has 
occurred at this institution. The children were given 500 units of anti- 



DIPHTHERIA. 533 

• 
toxin each, but it was apparent in a number of instances that immunity 
from diphtheria did not last for more than eighteen days to three weeks, 
at which time several cases of diphtheria occurred, complicating or follow- 
ing measles, and generally proved fatal. This relatively shorter period of 
immunity from diphtheria in measles cases has been noted in France and 
Germany, and for this reason Slawyk recommends that the immunizing 
dose be repeated every two weeks in measles epidemics. 

Krauss gives an extensive analysis of results of immunizing doses in 122 
hospital cases, which were divided as follows : 44 were scarlet fever cases, 
2 of which later contracted diphtheria; 31 cases of children were sent to 
the diphtheria pavilion and found not to have true diphtheria; no cases 
contracted it; 47 measles cases, many of them complicated; 1 developed 
diphtheria. 

Thus, of 122 cases, all of whom were more or less exposed to the dis- 
ease, and all ill with diseases most likely to be complicated by diphtheria, 
only 3 became infected, on the twenty-sixth, twenty-seventh, and forty-first 
day after inoculation. The dose of antitoxin ranged from 200 to 400 
units, the latter being given to the children with suspected diphtheria. 

Modern Treatment of Diphtheria. 

The treatment of diphtheria requires careful consideration in each and 
every case. Certain conditions must be met; therefore it is wise to look 
ahead. 

Hygienic Treatment. — Put the child to bed in a large, airy room. 
The room must be free from draught and so arranged that proper ventila- 
tion can easily be carried out. Fresh air in the treatment of this disease is 
of prime importance. Pseudo-membranous deposits in the nose, pharynx, 
larynx, or tonsils will frequently cause a mechanical impediment to the 
entrance of oxygen. Carbonic acid poisoning can easily take place, and 
the entrance of fresh air into the lungs is of the greatest importance. In 
simple diphtheria, or if we have an extension of the croupous deposits into 
the bronchi, perfect ox}^genation of the lungs is demanded. Having given 
attention to proper ventilation, we must seek to maintain an equal tempera- 
ture in the room. The temperature of the sick-room should be between 65° 
and 72° F. The entrance of sunlight is of prime importance. When we 
consider the great antiseptic properties of sunshine and its beneficial effect 
upon the patient, then we must see the importance of admitting as much 
light and sunshine as possible. 

The Bath. — Next in importance to fresh air and sunlight is the bath. 
Every patient with diphtheria should be sponged twice daily with a tepid 
sponge bath. The body should be briskly rubbed for a few minutes after 
the bath to stimulate the cutaneous circulation. By opening the pores of 
the skin we naturally favor elimination; hence it is advisable to encourage 
diaphoresis by attending to the skin. 



534 



THE INFECTIOUS DISEASES. 



Specific or Antitoxin- Treatment. 

Manner of Administering the Antitoxin. — The greatest amount of 
care should be exercised in administering antitoxin. The skin of the 
patient at site of puncture should be painted with tincture of iodine. The 
physician's hands and the needle used should be rendered aseptic. Disin- 
fect the syringe with alcohol. Abscesses need not form at the base of punc- 
ture if care and attention are bestowed to strict cleanliness. 

Part of the Body Chosen. — Wherever a loose fold of skin can be 
pinched up, for example on the thigh, the loose tissues of the abdomen, the 
outer portion of the chest, or between the shoulder blades, the needle 
should be inserted into the cellular tissue and the antitoxin gradually 
injected. The puncture should then be sealed with a drop of collodion. 
Fill the syringe with antitoxin and expel all air before injecting the 
patient. Sudden death after the injection of antitoxin has been reported 
when this precaution was neglected and air was injected into a vein. 

According to Ehrlich, the diphtheria toxin consists of three substances : 
toxoid, toxin, and toxone. The toxoid is harmless; the toxin is the cause 
of the acute symptoms, and the toxone is the cause of the late paralysis. 
The three substances are neutralized by antitoxin in the order named, so 
that an insufficient dose of antitoxin may neutralize the toxoid and toxin 
only, thus leaving the toxins still active and able to cause paralysis. 

Dose Required. — At the meeting of the Medical Board of the Willard 
Parker and Riverside Hospitals, held June 8, 1915, the committee 
appointed to formulate the dosage and method of administration of anti- 
toxin in the treatment of the various types of cases of diphtheria in the 
hospitals reported as follows : — 

Dosage of Antitoxin. 



Infants — 10 to 30 pounds in weight 
(under 2 years of age) 



Children — 30 to 90 pounds in weight 
(under 15 years of age) 



Adults — 90 pounds and over in weight. 



Mild Cases. 


Moderate. 


Severe. 


2000 

to 
3000 


3000 

to 
5000 


5000 

to 
10,000 


3000 

to 
4000 


4000 

to 
10,000 


10,000 

to 
15,000 


3000 

to 
5000 


5000 

to 
10,000 


10,000 

to 
20,000 



10.000 



15,000 

to 
20,000 

20,000 

to 
40,000 



It was decided that laryngeal diphtheria, moderate cases seen late at 
the time of the first injection, and cases of diphtheria occurring as a com- 
plication of the exanthemata should be classified and treated as "severe" 



DIPHTHERIA. 



535 



cases in this schedule. The committee recommended a single dose in all 
cases of the proper amount as indicated. The methods of administration 
recommended for mild and for moderate cases were intramuscular or sub- 
cutaneous; for severe cases intramuscular, subcutaneous or intravenous; for 
malignant cases intravenous. 

The dose of antitoxin for immunizing purposes was fixed at 1000 units. 

Severe Cases. — When we are dealing with a severe toxasmia with marked 
general depression and large masses of pseudo-membranes in the throat, 



190A- 


DATES OF OBSERVATIONS 


V^ 


15 


16 


17 


18 


19 


Cent. 


Fahr. 


am!pm 


am:pm 


AM 


PM 


am:pm 


AMiPM 


39° " 
33°~ 


- 
: 103 6; 


8 
I ; 

! 








; 




- 
- 

: 102°- 


3 A- 
5/ \ 
t \ 
I \ 








• 




• 
- 

:101°*j 










j 




• < 
: ioo° : j 


• 
• 
• 
• 








• 




37° 


h- 't 
-99° -5 


• 








\ 




•( 


. 










36° 


-98°-* 












• t 

• t 

: 97°-J 


3001 


Uklt 


t in,jt 


cM 




• i 

• t 

-96° ' i 


♦ 




•y 








Pulse 
per minute 


as 


>r5 
35 


5(© 


sr 


<** 


Respirations 
per minute 


Nq* 

^N 




siqai 


SI 



Fig. 167. — Temperature 
Specific Effect of Antitoxin 
the pulse. (Original.) 



Chart from a Case of Diphtheria, showing the 
on the Temperature. Note also the effect on 



then at least 10,000 units of antitoxin 1 should be injected in the beginning. 
When the cervical lymph glands are enlarged and there is slight or severe 
evidence of stenosis, then at least 10,000 units should be injected in the 
beginning. 



1 It is frequently necessary to repeat the dose, so that 10,000 units may be 
given during the first day of illness, if no improvement is noted. The dose of 10,000 
units may be repeated during the first three days if no improvement is noted. I am 
in favor of large doses and watch the child's condition as the guide when sufficient 
antitoxin has been injected. 



536 



THE INFECTIOUS DISEASES. 



Indications for a Second and Third Injection. — No positive rule can 
be made that will apply to all cases of diphtheria. While it may be wrong 
theoretically to give a second or third injection of antitoxin, I have seen 
cases where, even though a large injection was given at the beginning of 
the disease, it required a second and a third dose to stimulate the previous 
dose to activity. Thus my advise is to give a large dose at the beginning, 
but do not be afraid to repeat the dose after twenty-four hours if no objec- 
tive improvement is noted. 

Effect, of Antitoxin on the Blood. — It has been found experimentally 
by Dr. Park that if an injection of 10,000 units was given to children a 
second injection rarely was necessary. The antitoxin was found to reach 




Fig. 168. — No. 1 shows the method of transfixing and raising the vein 
with a sewing-needle and holding it in the elevated position by means of a 
hsemostat. The syringe needle is shown inserted into the vein beneath the 
transfixing needle. No. 2 shows more in detail the method of fixation and 
the insertion of the needle. No. 3 shows what frequently happens in at- 
tempting to insert the needle of the syringe without first fixing the vein. 
(After Watson.) 

the blood-stream slowly, increasing up to the third, fourth, or fifth day, 
and then slowly decreasing. That if the second dose were given twelve 
hours after the first the beneficial effects which might be attributed to it 
were really due to the continued absorption of the first dose, the second only 
contributing its share. It was also found that when antitoxin was given 
intravenously a large amount of it went into the blood-stream immediately ; 
therefore, this means should be used in desperate cases. 

Intravenous Injections. — The most rapid method of bringing the anti- 
toxin into direct contact with the toxin is by intravenous injection. The 
dose injected should be at least 10,000 to 20,000 units. The site of the 



DIPHTHERIA. 537 

injection preferred is the median basilic vein at the bend of the elbow. In 
very young infants the jugular vein is more preferable. With a supporting 
pillow at the nape of the neck the jugular vein stands out prominently and 
the technique of the injection is simplified. In many instances it will be 
necessary to expose the vein in order to successfully inject the antitoxin. 
With the aid of a 6 per cent, aqueous cocaine solution local anaesthesia can 
be sufficiently attained. If we are careful to exclude all air while injecting 
the antitoxin, no untoward symptoms will follow. If the site of the 
median basilic vein is chosen, compression above the bend of the elbow will 
make the vein stand out prominently. Sterilize the surface, and inject 
several drops of cocaine. Make a small incision across the course of the 
vein. 

The arm is corded above the elbow, so as to cause the vein to become 
distended and prominent. The vein is then transfixed with a straight 
surgical needle. The cord may then be loosened and the needle of the 
syringe inserted into the vein at right angles to and beneath the surgical 
needle, which is raised by a haemostatic forceps. Fig. 168 illustrates the 
advantages of this method. 

Laryngeal Stenosis. — It is always a safe plan to give an injection of 
5000 units; and if the stenosis does not disappear in twelve hours, I give 
an additional injection of 5000 units, so that, in all, 10,000 units may be 
injected during the first twenty-four hours (read article on "Intubation"). 

The above treatment with antitoxin will be serviceable when we are 
dealing with a pure Klebs-Loeffler infection, but there are a great many 
cases in which we have a mixed infection, and the streptococcus infection 
predominates. 

There are contributing factors frequently leading to a fatal termination. 
First and foremost is the presence of the streptococcus in addition to the 
Klebs-LoefTler infection. In these mixed infections we have, in addition to 
the general diphtheria, a distinct streptococcemia. In these cases antitoxin 
is inert as regards the streptococcus. We frequently have broncho-pneu- 
monia, nephritis, arthritis, otitis, and local abscesses due to the invasion of 
the streptococcus. To neutralize such mixed infection we require besides 
the Klebs-Loeffler antitoxin a streptococcus antitoxin or a potent antistrep- 
tococcus serum. 

The bacteriological findings will therefore be the guide in the future in 
determining, first, whether a culture from the throat shows a mixed or an 
unmixed infection and in addition to this bacteriological examination, the 
blood must be examined to determine the presence or absence of a strepto- 
coccemia. The treatment must be based on scientific data; hence it should 
conform with the result of what is found by culture from the throat and by 
the thorough examination of the blood. 

If we can inject a sufficient quantity of antitoxin to stimulate cell 



538 THE INFECTIOUS DISEASES. 

activity and neutralize general toxaemia, 1 then we give our patient the great- 
est opportunity to eliminate this deadly poison and to begin convalescence. 

The presence of pseudomembranes filled with Klebs-Lomer bacilli is 
a source of great danger. This danger consists in the liberation of the 
toxins and the producing of a profound systemic infection. The longer 
the membranes remain the moje systemic poisoning will take place. This 
poison will inhibit the functions of the heart, of the kidneys, and of the 
other vital organs of the body. Persistent membranes should, therefore, 
be regarded as of grave prognostic omen, and therapeutic measures should 
be directed towards exfoliating these membranes as rapidly as possible. 

In the early stages of diphtheria we do not encounter this toxaemia, 
but when the membranes remain, the toxins liberated by the pathogenic 
micro-organisms give a systemic poisoning ending in a toxic myocarditis 
or a toxic nephritis. It is important, therefore, to use vigorous treatment 
early, and correct thereby, if possible, the tendency to a general toxaemia. 

The toxic effect is noticeable on the nervous system. Such children 
are peevish and irritable by day and restless at night. The constant 
absorption of toxins from necrotic pseudomembranes located in the rhino- 
pharynx, larynx, or trachea, destroys the muscular energy and saturates 
and poisons the central nervous system. These are the immediate symp- 
toms seen during the early stages of the diphtheritic infection. When, 
however, this toxin is permitted to accumulate in the system it frequently 
causes permanent paralysis. This paralysis usually involves the lower 
extremities in the form of a multiple neuritis. Another danger consists in 
swallowing the pseudomembrane, and thereby infecting the stomach. 

The ordinary shortcomings that are most frequently met with consist 
of placing too much reliance on the specific nature of antitoxin regardless 
of other vital necessities. In this infectious disease, where there is marked 
leucocytosis and other evidences of subnormal haimic conditions, the indi- 
cation next to antitoxin is for restorative treatment, especially nutrition. 

Dietetic Treatment. — As a tissue and blood builder no medication 
equals food. It is, therefore, imperative to support the general nutrition by 
proper feeding. Milk diluted with some cereal decoction, like oatmeal, bar- 
ley or rice, will be better borne than pure milk alone. Buttermilk or zoolak 
may be given. Sometimes it is necessary to partially peptonize milk to 
render it more absorbable. If the child is old enough the yolk of a raw egg 
can be added to the milk (egg-nog). Concentrated beef broth, chicken 
broth, clam broth or oyster broth should be thought of. When feeding once 
in three hours, it is a good plan to give some of this concentrated broth, fol- 
lowed in three hours by a milk feeding, and so alternate. In this manner 
we give our patient milk once in six hours. Acid fruits, such as oranges, 

1 In septic diphtheria where profound toxsemia exists an intravenous injection 
of 10,000 to 20,000 units of antitoxin should be used. 



DIPHTHERIA. 539 

lemons, grapes, and cranberries, are very well borne. When acid fruits are 
ordered they should be given an hour before milk feeding. Older children 
can be given raw scraped steak, calf s-foot jelly, and ice cream, which is 
nutritious and pleasant. When it is difficult to feed by mouth owing to 
excessive vomiting or to anorexia, or where intubation has been performed, 
it is a good plan to let the stomach have absolute rest and to depend on : — 
Rectal Feeding. — No more than two ounces should be injected at one 
time. 

Milk, predigested 1 ounce 

Starch water . 1 ounce 

Laudanum 1 minim 

To be injected slowly through a colon tube after both colon and rectum have 
been cleansed by a soap-suds enema. 

If the small nutritive enema is well retained we can repeat the injection 
once every four hours, and add the yolk of a raw egg to the above formula 
of milk, starch, and opium. Next in importance to giving the proper dose 
of antitoxin is the nutrition of the body, which has just been considered. 

Elimination of Toxins. — The elimination of toxic elements can only 
take place by means of the bowels, kidneys, and skin. Normally in febrile 
conditions there is a general torpidity of the emunctories. Thus it is ap- 
parent that a dose of calomel, citrate of magnesia, or an alkaline solution, 
like the milk of magnesia or a laxative mineral water, will aid in the per- 
formance of these functions. 

Medicinal Treatment. — It is advisable to remove the putrid membranes 
from the nose and throat and also the catarrhal discharges. To do this, 
mechanical treatment consisting of the cleansing of the nose with a salt 
solution of the strength of one dram of table salt to one pint of water is 
useful. A weak (y 2 per cent.) solution of permanganate of potash can also 
be used to cleanse the nose with the aid of a syringe (see Fig. 200). 

Septic products in the nose and throat will frequently lead to a fatal 
termination. Their presence is a constant menace to the blood by inviting 
toxaemia. In addition thereto they give rise to fever and not infrequently 
septic material will find its way from the nose and pharynx into the 
Eustachian tubes, causing abscesses. If neglected it may lead to mastoid 
involvement and brain abscesses or to septic meningitis, with little or no 
chance of recovery. 

By observing the enlarged lymph glands, it is surprising to see what 
good result is apparent after cleansing the nose and pharynx. 

Local Treatment of the Pseudo-membranes. — The solvent effect of local 
remedies I have never been able to see. When papayotin has been used, I 
have been disappointed in its effect. Creosote vapor, by adding a dram of 
beechwood creosote to a pint of water and allowing the air to become im- 
pregnated with the vapor, has shown some good in a few instances. Lugol's 



540 THE INFECTIOUS DISEASES. 

solution of iodine (half -strength), applied by means of absorbent cotton, can 
be recommended. A steam atomizer containing a weak solution of 2 per 
cent, sulphurous acid is sometimes of value. The latter has been used by 
me and certainly can be recommended when there are extensive necrotic 
patches. It is far better than peroxide of hydrogen. 

Enlarged Lymph Glands. — Other local treatment which I have used 
with benefit is the inunction of unguentum Crede into the cervical glands, 
rubbed in at least fifteen to twenty minutes two or three times a day. An 
ice-bag worn continually can also be recommended when there is an extensive 
oedema. Some cases do better by the application of a warm flaxseed poultice 
covered with oil-silk, or by the application of a hot-water bag. 

Oxygen is indicated and required when there is the slightest evidence 
of cyanosis. It will also relieve dyspnoea when present. It is especially indi- 
cated during broncho-pneumonia, which so often complicates diphtheria. 

Fever Treatment. — It is a wise plan to exclude antipyretic drugs during 
the treatment of fever in diphtheria. The best antipyretic measures con- 
sist in sponging with evaporating lotions such as alcohol and water or acetic 
ether, locally. Cold packs and flushing the bowel with cold water are very 
serviceable in some cases. When high fever due to pneumonia, to nephritis 
or to any other complication exists, the same should be treated as though the 
disease existed independent of the diphtheria. 

When fever exists and the child cries continuously then the ears 
should be examined. Frequently an otitis media will keep up high fever 
until the drum is punctured. Ten- to 20- drop doses of sweet spirit of niter 
are valuable if given several times a day. During the febrile stage of 
diphtheria, calomel in 1 / 10 - to %- grain doses, repeated several times a day, 
is a useful adjuvant in fever treatment. 

Stimulation. — Owing to the depressing effect of the diphtheritic 
poisons, stimulation should begin early. Strychnine, 1 / 100 grain, for a child 
1 year old, repeated three or four times a day, may be given. The dose can 
be gradually and cautiously increased until a systemic effect is noticeable. 
Children will tolerate very large doses of strychnine just as they will tolerate 
very large doses of whisky. They can be combined. Tokay wine, cham- 
pagne and coffee are valuable cardiac stimulants. Caffeine citrate and 
sparteine are also serviceable for enfeebled heart's action. The prognosis 
of a case of diphtheria is certainly better in a case where the heart has been 
supported until the toxaemia has passed away. 

Paralysis. — The internal treatment of paralysis consists of strychnine 
and the usual restorative treatment. Galvanic and faradic electricity are 
good. Absolute rest in bed and gentle massage are indicated. 

Statistics of the Kaiser and Kaiserin Friedrich Hospital in Berlin 
show a very interesting comparison between the mortality before and after 
antitoxin was used. 



CHRONIC DIPHTHERIA. 541 

The death rate was 36.56, 35.57, and 45.78 in three successive years, 
or an average of 39.63 per cent. In the year 1894, when the serum treat- 
ment was first used, although experimentally, there were two interesting 
data: first, the mortality among cases treated with antitoxin was 16.6 per 
cent.; second, those treated without^ antitoxin, mortality 27.8 per cent. 
In the following year (1895) all cases of diphtheria were injected with 
antitoxin; the mortality fell to 11.2 per cent. 

Immunity. — Four hundred and sixty children were injected with the 
object of producing immunity. Of these only 18 came down with diph- 
theria. All of these cases were mild and not one died. 

A comparative study of the deaths before antitoxin was used and the 
present method of treatment, where all cases receive antitoxin, can hardly 
be made. I frequently see septic cases sent to the hospital in a moribund 
condition. The city hospital is used as a dumping ground for all malignant 
cases; hence the high mortality rate. The cases admitted belong to the 
laboring class of people. As these people are very poor, they delay sending 
for a physician until severe laryngeal stenosis sets in. When the disease 
has gained headway and there is a general septic condition, recovery, as a 
rule, is doubtful. 

Chronic Diphtheria. 

There are two varieties which characterize this condition : — 

The first form is simply the continuation of an acute attack of 
diphtheria, running a prolonged course. Second, a chronic form in which 
symptoms of pseudo-membranous rhinitis exist and which may be present 
months or years. 

In the prolonged type previously mentioned, fever, glandular swelling 
and general systemic disturbances mark the beginning of the attack. In 
the latter type the febrile manifestations and general constitutional dis- 
turbances are totally absent. 

Diagnosis. — The clinical picture of the chronic type of diphtheria 
narrows down to two distinct features : First, the presence of pseudo-mem- 
branes in the nose, pharynx, or larynx for months or years. Second, the 
persistence of the Klebs-Loeffler bacillus. Third, the marked absence of 
general constitutional disturbances. 

Neisser, v. Behring, Walb, and more recently Newfield describe this 
form of diphtheria. He found that a series of cases of rhinitis atrophicans 
and ozama showed Klebs-Loefner bacillus in addition to the ozaena bacillus. 
I have met with cases of this prolonged type of diphtheria which clinically 
resembled syphilis. 

Prognosis and Course. — Such cases require very careful observation and 
a very guarded opinion should be expressed as to the length of time that 
the condition will last. Not infrequently tuberculosis or some form of 



542 THE INFECTIOUS DISEASES. 

chronic broncho-pneumonia may follow with fatal result. In a case of 
chronic diphtheria extending over seven months which was complicated 
by entero-colitis during midsummer, the result was fatal. 

Isolation.— The presence of the Klebs-Loeffler bacillus demands the 
strictest isolation from all healthy persons. The virulent nature of the 
Lbeffler bacillus should be remembered. All children suffering with en- 
larged tonsils or those having adenoid vegetations should be carefully 
guarded against" exposure to a case of this kind, as they are more prone 
to infection than those having healthy throats. 

Treatment. — If we are dealing with a subnormal condition, the system 
must be built up with cbdliver-oil in addition to a concentrated diet, such as 
eggs, cereals, and broths. The most valuable drug, undoubtedly, is iron. 
The tincture of the chloride of iron, 10 to 30 drops, three times a day, or 
oftener, is very useful for its local as well as its systemic effect. I administer 
iron, regardless of its constipating tendency, for weeks and months. 

Locally, a bichloride spray or a spray of Dobell's solution can be used 
three or four time& a day. If after several weeks of persistent treatment 
no benefit results, then a decided change of air, such as a trip to the seashore 
or to the mountains, will assist in the cure of the patient. 

Intubation". 

When laryngeal stenosis occurs during a case of diphtheria, then we 
must prepare for intubation. 

The following symptoms demand intubation : — 

Labored breathing. 

A gradual and progressive dyspnoea. 

A failing or intermittent pulse. 

Cyanosis showing defective oxygenation. 

Retraction of chest wall most marked at epigastrium or at the clavicles. 

When the accessory muscles of respiration are brought into play. 

When the child is compelled to sit upright in order to breathe and 
pulls at its neck and throws itself from side to side, gasping for breath. 

The management of a case of intubation in private practice should be 
carefully considered. No child should be permitted to wear a tube in the 
larynx without the constant supervision of a trained nurse. In the Willard 
Parker Hospital we have competent trained nurses both night and day, and 
a physician is always ready to respond in case of emergency. I have fre- 
quently intubated in private practice and always give the following orders 
to the trained nurse : — 

First. — If the breathing becomes labored or if the child has a sudden 
increase in the number of respirations, notify the physician at once. 
j ': Second. — Watch the pulse; a sudden increase in the pulse-rate or a 
sudden, intermittent pulse means danger. 



INTUBATION. 543 

Table No. 55. — Diphtheria Cases — Willard Parker Hospital. 



Year. 


No. Treated. 


Died. 


Mortality 
Per cent. 


Eeeov' ries 
Per cent. 


Intubations. 


Recover- 
ies 
Inclusive. 


Recoveries 
Per cent. 


1901 


919 


275 


29.92 


70.08 


222 


70. 


31.53 


1902 


1112 


271 


24.37 


75.63 


258 


116 


44.92 


1903 


1281 


356 


27.79 


72.21 


352 


123 


34.94 


1904 


1402 


356 


25.39 


74-61 


410 


193 


47. 


*1905 


478 


98 


20.50 


79.50 


154 


86 


56. 


Total 


5192 


1356 


26.12 


73.88 


1396 


588 


42.13 



*On account of rebuilding the Hospital, no patients were received after June 17th. 

Third. — If cyanosis or sudden apncea occurs, possibly caused by a 
plugging of the lower portion of the tube with membrane, notify the physi- 
cian so that the tube can be extubated and a tube of larger caliber inserted. 

Fourth. — If the tube is suddenly expelled during a paroxysm of cough- 
ing (auto-extubation), a hurry call should be sent to the physician. 

What to Do in an Emergency. — First. — Give a mustard foot-bath or 
apply a mustard plaster over the heart to stimulate the circulation. 

Second. — Give 5 to 10 drops of aromatic spirits of ammonia with an 
equal quantity of whisky. Nitroglycerine can be given in Vioo'grau 1 doses 
every hour, hypodermically if necessary. 

Third. — Eelieve the stenosis, if it exists, by careful intubation. 

Fourth. — If an expert intubator is not at hand, or if intubation pushes 
membrane downward so that the stenosis persists, resort to tracheotomy. 

Eegarding extubation, my rule in private practice is to extubate on the 
fifth' day, or on the morning of the sixth day, provided the temperature is 
normal and no complication exists. It is safer to leave a tube in the larynx 
one day longer than risk the necessity of reintubation. 

My two principal rules in intubation and extubation are : First, avoid 
force, thereby avoiding injury. This rule has been my greatest aid in 
preventing retained tubes. Second, do not hurry. While in a severe laryn- 
geal stenosis a given amount of haste is necessary in selecting the proper- 
sized tube and making preparations, when it comes to the introduction of 
the tube, the inflammatory process and subnormal condition must be remem- 
bered; hence, go slow. 

The nervous, frightened child must be quieted, especially when con- 
sidering extubation. I usually order an antispasmodic for twelve hours pre- 
ceding the removal of the tube. Codeine, % grain or 1 / 3 grain to a child 



544 THE INFECTIOUS DISEASES. 

Table No. 56. — Showing Number of Intubated Cases and Percentage Mortality unth 
Relation to Number of Hours Spent in Willard Parker Hospital. 

1910 

Total number intubated cases 348 

Total number intubated cases discharged 203 

Total number intubated cases died 145 

Percentage mortality 41.67 

Total number intubated cases dying within twelve hours 21 

Percentage mortality 6.03 

Total number intubated cases dying within twenty-four hours 33 

Percentage mortality 9.48 

Total number intubated cases dying within thirty-six hours . . 23 

Percentage mortality 6.60 

Total number intubated cases dying within forty-eight hours 22 

Percentage mortality 6.32 

Percentage mortality 348 intubated cases less forty-eight-hour cases.... 13.21 

2 years old or older, is repeated every three hours for four doses, or 10-grain 
doses of sodium bromide, with 2 grains of chloral hydrate, repeated in six 
hours — two doses only — will allay nervous excitability and have a quieting 
effect. Antispasmodics should be continued for twenty-four hours after 
removal of the tube. The spasm due to fear of the operating table when 
repeated in- and ex- tubation is practised may in rare cases require the 
inhalation of a few drops of ethyl chloride prior to extubation. Dover's 
powder is a valuable drug as an antispasmodic. 

Indications for Intubation. 1 — "The indications for intubation are 
marked by a more or less sinking in of the yielding portions of the chest, 
lower ribs and sternum, episternal notch, and supra-clavicular regions with 
inspiration. It means simply that air cannot gain entrance to the lungs in 
sufficient quantity to fill the partial vacuum created by the expansion of the 
chest, and the wall recedes under the weight of the atmosphere. It is very 
marked in very young or rachitic children owing to the greater elasticity of 
the ribs. But it should be remembered that this condition is not peculiar 
to stenosis of the larynx and trachea, as it is produced to a lesser degree by 
obstruction in any part of the respiratory tract that interferes with the 
free inflation of the lungs. It is found in capillary bronchitis, extensive 
deposits of pseudo-membrane in the bronchi, atelectasis, and to some extent 
even in broncho-pneumonia. Secessions at the root of the neck are more 
significant than those below, as the violent contractions of the diaphragm 
aid in drawing in the free border of the ribs and sternum. 

"When recessions are marked there is little or no respiratory murmur 
over the posterior portion of the chest, but this symptom is not always avail- 
able owing to the laryngeal stridor. 



x From O'Dwyer's treatise on "Intubation" in his book, "Diphtheria and 
Croup," 1889. 



INTUBATION. 



545 



"Atelectasis with excessive quantity of blood in the lungs, as would 
naturally be expected, is the result of death from obstruction in the 
larynx, but there are exceptions to this rule, and these organs are occa- 
sionally found distended with air and containing less than the normal 
amount of blood. This acute general emphysema, which produces bulging 





Fig. 169. — Introducer with Tube Attached. 




Fig. 170. — Introducer with Tube and Detached Obturator. 




Fig. 171. — Introducer Holding Foreign -body Tube 



of the parts that usually recede, is caused by greater impediment to expira- 
tion than inspiration, and air accumulates in the lungs in the same manner 
as in spasmodic asthma. It is not common in croup, but is worth remem- 
bering. It is also occasionally found in capillary bronchitis. 

"The downward movement of the larynx with inspiration is pathogenic 
of serious obstruction in this organ, and is also the result of atmospheric 

35 



546 



THE INFECTIOUS DISEASES. 



pressure, the air being prevented from entering with sufficient rapidity to fill 
the partial vacuum below. It is readily detected in adults, but not so 
in children, owing to deeper situation of the larynx in the latter. 

"This symptom is not present in stenosis of the trachea, owing to the 




Fig. 172.— Extubator. 



great elasticity of this tube, which permits of considerable motion on itself 
without displacing the larynx. 

"Abiding cyanosis is too late a symptom to wait for, and, besides, it is 
uncertain, as fatal obstruction may exist in the glottis with extreme pallor 




Fig. 173. — Built-up Tubes for Granulation Tissue. Useful for 
treatment of "retained tubes." 

on the surface. This pallor of asphyxia is produced by the excessive 
quantity of blood drawn into and stored in the lungs by the cupping-glass 
action of inspiration when the air is almost excluded. The blood in the 
cutaneous capillaries is thus reduced to a minimum, and this, although 
highly charged with carbonic. acid, only serves to increase the paleness, on 
the principle that the addition of a little blue makes a clearer white. 



INTUBATION. 547 

"The temporary cyanosis which comes and goes with the paroxysmal 
dyspnoea of the second stage of croup is of no particular significance. 
Children seldom remain long in one position when suffering severely from 
want of breath, and continued restlessness, if consciousness be unimpaired, 
is therefore an important indication that it is time to afford relief. 

"As far as the necessity for intubation is concerned, it matters little 
as to the real nature of the obstruction, provided it be in the larynx and not 
a foreign body. It may be croup, simple laryngitis, oedema of the glottis, 
paralysis, spasm, or even a neoplasm. In the latter it will tide over the 
immediate danger of asphyxia, and leave more breathing room to facilitate 
the radical operation." 

Dorsal Method of Intubation. — This method is the most convenient, as 
it does away with the necessity of several assistants. I have frequently in- 




Fig. 174. 1 — The Mummy Bandage, showing child in proper position for 
the dorsal method of Intubation. All instruments required are carefully 
arranged. ( Original. ) 

tubated in the dorsal position without any assistant. This method appeals 
to me as very valuable in emergencies, especially so when a physician is 
called out of town where no trained assistant is available. The method of 
introducing the tube is the same as that described as the O'Dwyer method. 
The dorsal method has been advocated by the attending and resident staff 
at the Willard Parker Hospital and is the method employed there now. 

The gag should be inserted into the left side of the mouth, and slowly 
opened. The trained nurse steadies the child-s head and holds the gag in 
place. With the child flat on its back, the hands firmly held by a blanket 
encircling the body, the physician stands on the right side of the child and 
introduces the index finger of his left hand in the median line until the 
epiglottis is felt. The epiglottis should be raised and fixed. The tube 
should then be guided with the right hand of the operator, along the left 



1 The set of photographs illustrating intubation, extubation, and gavage were 
taken in the wards of the Willard Parker Hospital. 



548 



THE INFECTIOUS DISEASES. 



index finger, and inserted into the cul-de-sac of the larynx. It would be 
profitable to read O'Dwyer's description of the method of intubation which 
I append here, the only difference being that O'Dwyer recommends the sit- 
ting position, whereas I advocate the dorsal position. 

Upright Method of Operating.— "The nurse or person who holds the 
child should be seated on a solid chair with a low back, and the patient 






mm m 



Fig. 175. — Intubation. Left index finger raising the epiglottis. The intro- 
ducer with tube attached is glided along the finger. (Original.) 



placed on the lap with head resting on left shoulder of nurse' in order to 
leave the gag free. The hands can either be held or, still better, secured by 
the sides, by a towel or sheet passed around the body and left in that 
position until the tube is inserted and the string removed. Fastening the 
hands in front of the chest or thick garments in the same location renders 
it more difficult to depress the handle of the introducer sufficiently to carry 
the tube over the dorsum of the tongue. 

"The gag is then inserted well back behind or between the teeth in the 
left angle of the mouth and opened widely, care being taken not to do it 



PLATE XXY 




Intubation. First step. Index finger raising the tip of the epiglottis. 
The tube guided along the finger. (Original.) 




Intubation. The tube passing the epiglottis. Entering the larynx. (Original.) 



INTUBATION. 



549 



too suddenly or to use too much force. In children who have not at least 
one bicuspid on the left side, the gag should not be used, as it slips forward 
on the gums, and, besides being in the way, is liable to injure the incisor 
teeth. There is little difficulty in these cases in keeping the mouth suffi- 
ciently open with the finger, if carried far enough to the patient's right 
to be out of range of the front teeth. Allowing the child to compress the 




Fig. 176. — The tube, passing the epiglottis, entering the larynx. (Original.) 



finger between the gums for a few seconds until the jaws relax, before carry- 
ing it into the fauces, avoids the necessity for using force. 

"An assistant stands behind the patient and holds the head firmly by 
placing one hand on either side, and at the same time slightly elevates the 
chin. The operator stands in front of the patient, holding the introducer 
lightly between the thumb and fingers of the right hand, the thumb resting 
on the upper surface of the handle, just behind the knob that serves to 
detach the tube, and the index finger in front of the trigger support under- 
neath. Held in this manner it is impossible to use force enough to make 



550 



THE INFECTIOUS DISEASES. 



a false passage, while if firmly grasped in the hand the beginner may, uncon- 
sciously, exert sufficient force to lacerate the tissues. 

"The index finger of the left hand is carried well down in the pharynx 
or beginning of oesophagus and then brought forward in the median line, 
raising and fixing the epiglottis, while the tube is guided along beside it into 
the larynx.. If any difficulty is experienced in locating the epiglottis, it is 
better to search for the cavity of the larynx, a cul-de-sac into which the tip 
of the finger readily enters, and which cannot be mistaken for anything else. 
Once in this cavity, the epiglottis must be in front of the finger and the latter 



VOCAL CORDS 




Fig. 177. — Tube, resting on vocal cords, in the larynx. (Original.) 



is then raised and pressed toward the patient's right to leave room for the 
tube to pass beside it. The distal extremity of the tube should be kept in 
contact with the finger, and even directing it a little obliquely toward the 
right side of the larynx if necessary to get inside the left aryepiglottic fold, 
especially in very young children. The handle of the introducer is held 
close to the patient's chest in the beginning of the operation, and rapidly 
raised as soon as the end of the tube has passed behind the epiglottis; other- 
wise it will slip over the larynx into the oesophagus. 

"Some operators hold the introducing instrument in the horizontal 
position until the tube is well back in the fauces, and then swing it around 
to the middle line and complete the operation in the usual manner. The 
beginner is liable to forget the latter movement, which is the only objection 
to this plan. 



PLATE XXVI 




Extubation. First step. Gag in position. Extractor is guided along the left 
index finger until the beak enters the lumen of the tube. (Original.) 




Extubation. Second step. The beak of the extractor holding the tube firmly: 
the operator withdraws the tube. (Original.) 



INTUBATION. 



551 



"As soon as the cannula is inserted the introducer with obturator at- 
tached is withdrawn by pressing forward the button on the upper surface 
of the handle with the thumb, while counter-pressure is made- with the 
index finger on the trigger beneath. In removing the obturator — the joint 
in the shank of which is intended to facilitate this part of the operation — 
the movements required for insertion are reversed. To prevent the tube 




Fig. ITS. — Extubation. The left index finger finding the tube. The 
beak of the extractor guided into the opening of the tube before removal 
of the tube. (Original.) 



from being also withdrawn, the finger must be kept in contact with its 
shoulder either on the side or posteriorly. 

"The tube should be carried well down in the larynx before detaching 
it; otherwise the lower aperture will be left open and liable to strip off 
pseudo-membrane as it is "subsequently pushed home with the finger. 

"The gag is removed as soon as the tube is in place, but the string is 
allowed to remain in place long enough to be certain that the dyspnoea is 
relieved and that no loose membrane exists in the lower portion of the 



552 



THE INFECTIOUS DISEASES. 



trachea. In some cases the presence of the thread is desirable because it 
excites more coughing, which is necessary to expel accumulated secretions 
and to innate any collapse of the lungs that may have taken place. In 
removing the string the finger must be reinserted to hold the tube down, 
but the gag is rarely necessary, as children old enough to understand readily 
open the mouth for this purpose." 

The characteristic tubal cough due to a rush of air through the tube 
when in the larynx, if once heard, will always be remembered. Usually the 





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Fig. 179. — Baby K., nursing infant, eleven months old, suffered with 
Laryngeal Diphtheria complicated by Broncho-pneumonia. Stenosis re- 
quiring intubation. Case seen in consultation with Dr. Kahrs in Bronx. 
Tube remained in larynx nine days. Child recovered. Private practice 
case. (Original.) 



presence of the tube excites a paroxysm of coughing and large quantities of 
mucus and membrane will frequently be expelled. The effect most no- 
ticeable is the immediate relief of the laryngeal stenosis. It is wise to wait 
five or ten minutes before withdrawing the silk thread that has been placed 
in the tube. After cutting the thread the finger should again be placed 
over the head of the tube, and the tube firmly pressed down while the string 
is withdrawn. 



INTUBATION. ■ 553 

There are several important points which must be emphasized in this 
operation. In the first place no force is necessary. "Occasionally a mo- 
mentary spasm retards the immediate entry of the tube into the larynx, in 
which case, rather than use force, it is best to wait a second or two for this 
to relax, when the tube will fall into place. The introducer should be held 
lightly between the end of the thumb and finger, and not grasped firmly in 
the hand. The introducer should be kept exactly in the middle line ; other- 
wise the obturator will pinch in the caliber of the tube and drag the latter 
with it as it is withdrawn. It often happens that the child manages by one 
effort to slip down in the nurse's lap, while the grasp that the assistant 
exerts tilts the head back, and the tube may impinge on the posterior wall of 
the larynx. The lines and angles must be maintained to insure quick 
intubation. The lack of observance and carelessness in these points 
explain many failures of inexperienced operators. If the tube is not 
properly placed at the first attempt, it is better to begin all over, making 
repeated, short attempts, if necessary, rather than a single, prolonged one" 

Accidents During Intubation. — An inexperienced operator will fre- 
quently be rewarded by fatal asphyxia. Prolonged attempts to introduce 
the tube will result in apnoea. 

"Ten seconds is the longest time that should be occupied in each 
attempt, if the child is suffering from urgent dyspnoea at the time/' A 
child cannot breathe while the finger is. in the throat. Eepeated attempts 
will so exhaust the vitality of a child that this must be reckoned with. 

"The expert seldom requires more than five seconds to complete the 
operation, except in difficult cases, such as a very small mouth and throat, 
marked increase in the size of the tonsils, especially if chronic; extreme 
tumefaction of the epiglottis and aryepiglottic fold, which changes or ob- 
literates the usual landmarks, and the struggles and resistance sometimes 
offered by older children when intractable. In the latter, although I have 
never had to resort to it, the administration of an anaesthetic would be less 
injurious than the exhaustion and cyanosis induced by a prolonged struggle 
without it. 

"If the tube has once passed on the outside of the larynx, and this is 
recognized before it is detached from the obturator, it is useless to try to 
rectify the position without first depressing the handle of the introducer as 
in the beginning of the operation, because, owing to the length of the tube, 
the palate arrests the upward movement before the distal extremity reaches 
the level of the glottic opening. 

"In croup the ventricles of the larynx are usually obliterated by swelling 
of the tissues and covered over by the pseudo-membrane, and therefore 
seldom offer any obstacle to the passage of the tube on the first introduc- 
tion; but when the stenosis persists longer than usual and reintroduction 
becomes necessary, it is well to remember that this may be a source of ob- 



554 ' THE INFECTIOUS DISEASES. 

struction. The tube once having entered a ventricle, a moderate amount 
of force is all that is necessary to make a false passage. I have known this 
accident to occur when the operator was unconscious of having used any 
force whatever. If the patient's head be thrown too far back, the tube may 
also be arrested by coming into contact with the anterior wall of the larynx 
or trachea." 

An accident, which fortunately is very rare, is the pushing of mem- 
brane downward. In this condition stenosis will not be relieved. In such 
cases it is advisable to extubate at once, and to reintubate by using one of 
the specially constructed tubes. 

Specially Constructed Tubes (see Fig. 173). — Caliber tubes, made of 
metal, also known as foreign-body tubes, have a much wider lumen than 
the ordinary tubes used for intubation. They are also shorter. Through 
these tubes large membranes are frequently expelled. There are instances, 
however, where large pseudo-membranes extend into the trachea to the 
smallest ramifications of the bronchi. Violent coughing paroxysms fre- 
quently dislodge these membranes, so that distinct casts of the trachea 
and its bifurcation can be plainly made out. Several of these casts were 
seen by me during my service at the Willard Parker Hospital. 

Intubation in Chronic Stenosis of the Larynx. — O'Dwyer's rules and 
indications for the performance of intubation in chronic laryngeal stenosis 
are as follows: (1) Cicatricial stenosis, due to injury to the soft parts from 
syphilis, irritants, and traumatism. (2) Narrowing of the space both below 
and above the vocal bands from the products of chronic inflammation — 
simple, tuberculous, specific, malignant, or otherwise, and including such 
conditions as the so-called pachydermia laryngis, and corditis vocalis inferior 
hypertrophica. (3) It is especially valuable in cases in which tracheotomy 
has been performed, and, when the tracheal cannula having been worn for a 
considerable length of time, the upper part of the trachea is filled with 
granulations and the laryngeal muscles have become weakened from disease. 
In this condition intubation has effected many brilliant cures. (4) In 
papilloma of the larynx it has been found helpful in a fair proportion of 
cases, although its results in this disease are less satisfactory than in most 
others in which it has been employed. (5) Deformities of the larynx from 
injury or disease of its cartilaginous framework, which have resulted in 
constriction of the caliber of the organ, have been cured by it. (6) It has 
also been used, with excellent results, in anchylosis of the crico-arytenoid 
articulations, and in arthritis deformans of the same part. (7) It is useful 
in various affections of the nerves of the larynx ; for instance, in hysterical 
contraction of the abductors, "aphonia spastica." 

The Tolerance of the Larynx for the Intubation Tube. — I have fre- 
quently seen children walking around the wards of the Willard Parker 
Hospital who have worn intubation tubes about two years. When one con- 



INTUBATION. 555 

siders the anatomical structure of the larynx, it is surprising that no 
inflammatory condition results from the presence of this foreign body. In 
the article on "Broncho-pneumonia" I report a case of diphtheria com- 
plicated by croup and later by broncho-pneumonia. Intubation was re- 
quired for the relief of laryngeal stenosis. Owing to severe paroxysmal 
cough, autoextubation resulted, requiring, in all, twenty intubations. The 
case finally recovered. 




Fig. 180. — Gavage. .Method used in Forced. Feeding at the Willard Parker 
Hospital. (Original.) 

Ulcerations due to 'the intubation tube have been seen by me : — 

(1) In the cricoid division of the larynx, just below the vocal cords. 

(2) At the base of the epiglottis, from pressure during the act of 
swallowing. 

(3) On the anterior wall of the trachea near the distal end of the tube. 
Ulcerations resulting from an intubation tube have been seen by me 

post-mortem in children that were fed by gavage. I have also seen ulcera- 
tion where children were fed by the natural methods. I believe that feed- 
ing with the swallowing movements incidental to the same produces ulcera- 
tion at the lower end of the tube, because of the up and down riding of the 
tube. 



556 



THE INFECTIOUS DISEASES. 



A post-mortem specimen of larynx and trachea was recently examined by me 
at the Willard Parker Hospital. The child was in the hospital twenty-one days; 
it was therefore an acute laryngeal stenosis. Three ulcerations existed at the 
cricoid cartilage and nine other ulcerations existed at the distal end of the tube. 

Feeding' After Intubation. — Various methods of feeding are in vogue, 
and each clinical observer seems to be satisfied with his particular method. 
Whenever possible we should try to resort to the usual mouth feeding. I 
invariably feed semi-solid food, such, as bread soaked in milk, custard, 




Fig. 181. — Casselberry Method of Feeding. (Original.) 



junket, cornstarch or rice pudding, soft-boiled eggs, if the child's age war- 
rants it; also concentrated soups and broths, calfsfoot or chicken- jelly, water 
ices and ice cream. These articles of food I have found best adapted in a 
very extensive experience in hospital and consultation practice. 

In very young infants, breast or bottle fed, great care should be exer- 
cised with the feeding. • If a breast-fed child refuses to nurse, the breast- 
milk can be pumped off and the infant fed every three or four hours by 
spoon. 

My advice in intubated cases: Use natural methods of feeding — do 
not use gavage — choose simple ways. Eectal feeding may be tried if 
vomiting occurs. 



INTUBATION. 



557 



The CasseTberry method of feeding consists in laying the child flat on 
its back across the nurse's lap, with the head below the level of the body. By 
this means we avoid introducing liquids into the larynx. 

Mamie B., 2 years old, was seen by 
me through the courtesy of the attending 
physician, Dr. H. Weinstein, on the second 
day of her illness. There were patches of 
diphtheria visible on the pharynx and ton- 
sils. The temperature was 101 2 / 6 ° F., 
pulse 140. There was also laryngeal in- 
volvement noticeable by the croupy cough. 
An injection of 2000 units of antitoxin 
was first given. The colon was flushed 
and the bowels thoroughly emptied. A 
dose of calomel was given and milk and 
albumin water ordered for the diet. 

Nasal irrigations of saline solution 
were ordered every two hours. An ice-bag 
was applied to the neck. On the third 
day the temperature rose to 102° F., pulse 
130, respiration 36. Breathing labored — 
considerable retraction of the chest — cough 
very croupy. Large quantities of mucus 
were expectorated. The pulse was 146, 
respiration 40. Stimulation was de- 
manded and 1 drachm of whisky was 
given every hour. Laryngeal stenosis was 
so severe that a hurry call was sent to me 
to intubate. The child was quickly in- 
tubated. A No. 3 rubber tube having a 
coating of gelatine and alum was inserted. 
The stenosis was immediately relieved. 
The child appeared comfortable and fell 
asleep. Six hours after the intubation 
the temperature was 103° F., pulse 140, 
respiration 40. Cold sponging was ordered 
and, owing to severe coughing when liquids 
were given, semi-solids were ordered while 
the intubation tube was in situ. On the 
following day the temperature dropped 
to 101.6° F., and on the third day after 
intubation the child was practically nor- 
mal. The tube was left in the larynx 
five days, and as soon as the temperature 
dropped to 99° F. the child was extubated. 
The patient made an uneventful recovery. 

No complications followed. I might add that the usual rule of administering 15 
grains of bromide of sodium or 7 ia grain of sulphate of morphine, as an anti- 
spasmodic, one hour before extubation was not given in this case. 




Fig. 182. — Temperature Chart from 
a Case of Diphtheria: Croup, In- 



tubation. ( Original. ] 



558 



THE INFECTIOUS DISEASES. 



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eneral condition fair. Sub- 
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and bronchitis lately. 


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Measles and bronchitis 
after discharge. 


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good. Measles shortly after 
convalescence. Mild attack 
of croup two years later. 
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560 THE INFECTIOUS DISEASES. 



A Study of the Condition or the Upper Air Passages Before and 

After Intubation of the Larynx. Also, an Inquiry Into 

the Method of Feeding Employed in the Cases. 1 

Laryngeal stenosis will frequently be relieved after one intubation and 
one extubation. There are other cases which require several intubations 
before a permanent cure results. 

I have examined a series of children that were operated upon several 
years ago. Two classes of cases have been selected. One series was seen at 
the Willard Parker Hospital, and the cases were intubated by the resident or 
assistant resident physician. The cases in this series cover the years 1896 
to 1900, and were under treatment of Dr. E. Gr. Bryant and Dr. Somerset. 

First Series. Children Intubated in the Hospital. — The children ad- 
mitted to the Willard Parker Hospital belong, as a rule, to the laboring 
class of people. Exceptionally, the service at the hospital receives patients 
of a better class. All of the children examined by me belonged to the tene- 
ment house district of New York City. The houses are densely crowded 
tenements having a minimum quantity of fresh air and sunlight. It is 
not unusual to see cases from such unsanitary surroundings ending fatally. 
These children are, as a rule, very anaemic and are extremely susceptible to 
infection. 

Hospital Cases : 10. 
8 cases required one intubation 
1 case required three intubations 
1 case required four intubations 

Day of the Disease. 

4 cases were intubated on the 2d day of illness 

1 case was intubated on the 3d day of illness 

2 cases were intubated on the 4th day of illness 
1 case was intubated on the 5th day of illness 
1 case was intubated on the 9th day of illness 
1 case was intubated on the 14th day of illness 

One case intubated seven years ago has had no illness since. Four 
cases intubated six years ago are in excellent health to-day. One case has 
remained entirely well. One case had enlarged cervical lymph nodes. One 
case had pneumonia one year later. One case had pneumonia and paralysis 
and five years later had a second attack of diphtheria, but no laryngeal 
stenosis. 

Five cases intubated three years ago are in good condition to-day. 
Three had measles and bronchitis after recovery. One has not had a 



1 Paper read before the International Medical Congress held at Madrid, Spain, 
April 26, 1903. 



INTUBATION. 561 

day's illness since intubation. One case had a mild attack of croup two 
years after intubation, but did not require reintubation. 

Rachitis seems to play an important part in the causation of laryngeal 
stenosis, just as we know that rickets is met w^ith in laryngismus stridulus. 
Eight cases out of the 10 reported in this series showed some form of 
rickets. 

There seems to be a certain predisposition for the development of 
laryngeal stenosis in children affected with diphtheria who are rachitic. 

Condition of the Throat. — In all of the cases of this series some form 
of chronic tonsillar or pharyngeal condition was found. Adenoids were also 
seen in 2 of these cases. Whether or no the hypertrophied tonsils seen in 
these cases were present at the time of intubation is not known. The fact 
that 8 cases out of 10 still showed enlarged tonsils, and 1 case, which makes 
9 cases, reported having had a tonsillotomy performed, proves that hyper- 
trophied tonsils must have menaced the children's health before the 
diphtheria. . 

Feeding During Infancy. — It is certainly an interesting fact that all 
of the children in this series were breast-fed. When abnormal conditions, 
as rickets, scurvy, tuberculosis, syphilis, or other undermining disorders, 
exist, then recurring stenosis of the larynx might possibly be provoked by 
such chronic disease. 

These cases of recurring stenosis sometimes require months and, in 
rare instances, years of intubating until recovery takes place. I have fre- 
quently seen chronic tube cases while making my rounds in the wards at the 
Willard Parker Hospital. 

Intubation has, in America, entirely replaced tracheotomy for the 
relief of acute laryngeal stenosis. Eubber tubes are used exclusively for 
intubation. The old metallic tubes have long ago been discarded. Trache- 
otomy is used as a secondary operation, usually to cure "retained tubes." 
When laryngeal stenosis persists and the patient cannot get along without 
the tube, then a tracheotomy is frequently resorted to. 

Jennings, of Detroit, with an equally large experience, says that 
he has never met with the severer forms of the difficulty, but that in two or 
three instances he has had to continue the intubation as late as the third 
week after the first insertion, before recovery was complete. His associate, 
Shurley, has never had any trouble with delay in the removal of the tube. 
Galatti, in the article above referred to, states that he had 2 chronic 
stenoses in 31 intubations. He reports Eanke as having had 1 case in many 
hundred; Heubner, 1 in 250, and Bokay, 2 in 800. McNaughton, of Brook- 
lyn, says that he has had but few cases in many hundred, and these recovered 
at the latest within several weeks. 



562 TH E INFECTIOUS DISEASES. 

At the Nursery and Child's Hospital of New York City there have been 
no noticeably prolonged intubations. The New York Foundling Hospital 
has had 6 cases in a total of approximately 500. Investigation of the statis- 
tics at this institution forcibly illustrates the advantages in the use of 
the diphtheria antitoxin. The house physician complained to Dr. Eogers 
that before the introduction of this remedy his predecessors had always 
averaged at least one intubation a week, and thereby obtained much valuable 
experience; but about the time he came into the hospital, the rule was 
instituted that antitoxin should be given to every patient as soon as there 
was any suspicion of diphtheria. The result was that he had never in a 
year's service had a single opportunity to practice intubation on a living 
subject. 

The Dorsal Method of Intubation. — Elsewhere in this article I have 
referred to the dorsal method of intubation. The great advantage in this 
method lies in the fact that an intubation tube can be inserted in a child 
suffering with laryngeal stenosis with the aid of the mother or nurse 
alone. With the child lying on its back, the arms and feet pinned in a 
blanket or sheet to prevent struggling, any intelligent person can steady 
the head and hold the gag in position at the same time, while the physician 
has both hands free for the introduction of the tube. 

The older method required an assistant to hold the child in an up- 
right position, and a second assistant to stand behind the child's head to 
steady the same and to hold the gag in position. The experience gained in 
the hospital with both methods has led us to abandon the older method 
entirely. 

Second Series. Children Intubated in Private Practice. — The children 
of this series were seen in consultation with the family physician, excepting 
1 case (Case 11), which was referred to me for personal treatment. They 
belong to the better class of children, which implies better sanitary sur- 
roundings, better food and prompt medical aid when the first symptoms of 
illness are noticed. It was much easier to study this series of cases, as 
the physician in attendance, as a rule, gave me the required data. 

Case X should be excluded in this study, as the child coughed up its 
tube (auto-extubation) and died of asphyxia before the physician arrived. 
Case IX must also be excluded, as it was impossible to obtain satisfactory 
details concerning the progress of the case after it recovered from the 
diphtheria. 

6 cases were intubated 8 years ago 

1 case was intubated 7 years ago 
4 cases were intubated 5 years ago 

2 cases were intubated 4 years ago 
2 cases were intubated 3 years ago 
9 cases were intubated 2 years ago 



INTUBATION. 563 

t> 
One of the cases in this series contracted scarlet fever and died two 
years after intubation. So that 3 cases out of this series must be excluded 
leaving 23 cases from which reports have been received. 

Day of the Disease. 

1 case was intubated on the 1st day of illness 
11 cases were intubated on the 2d day of illness 

9 cases were intubated on the 3d day of illness 

2 cases were intubated on the 5th day of illness 

Number of Intubations Required. 
15 cases required one intubation 

2 cases required two intubations 

3 cases required three intubations 

1 case required four intubations 

2 cases required five intubations 

Length of Time the Tube was Worn. 
1 case 26 days 2 cases 7 days 

1 case 25 days 5 cases 6 days 

1 case 22 days 8 cases 5 days 

2 cases 14 days 1 case 4 7 2 days 
2 cases 12 days 

The average length of time the tube was worn in the above 23 cases was 
9y 2 days or 228 hours. 

Rachitis. — In this second series of cases we are dealing with children 
brought up in excellent surroundings. In the families of the better class 
in New York City the majority of mothers do not nurse their own infants. 
Wet-nurses are not commonly employed. Thus the larger number of these 
children are to-day brought up by bottle feeding. It is, therefore, no wonder 
that in the present series of cases rickets due to malnutrition or inanition 
was very frequently encountered. The susceptibility of the rickety child has 
frequently been mentioned by many authors. In this second series of cases 
rachitis was associated in 19 cases. 

Condition of the Throat. — Not one of these cases had a normal throat 
at the time of the intubation. Adenoid vegetations, enlarged tonsils, and 
chronic rhinopharyngitis were met with in almost every case. When the 
danger of a diphtheritic laryngeal stenosis in a child is considered, then it 
is certainly important to urge the removal of hypertrophied tonsils or 
adenoids if present, and to restore normal conditions in the rhinopharynx 
if possible. Greater attention should be bestowed on the nose, as the most 
fatal cases are those of nasal diphtheria in which general sepsis follows. 

After-effects Resulting -from Intubation. — While some physicians have 
reported the existence of a bronchial catarrh during the first and second 
winter months following intubation, the majority of these 16 cases reported 



564 



THE INFECTIOUS DISEASES. 



absolutely normal conditions. Two cases have had pneumonia, in one child 
five years after intubation and in the other child three years after intuba- 
tion. 

One very interesting case in this series was a child (an idiot) 4 years old, seen 
in consultation with Dr. C. Hoffman. This was one of the most trying cases and 
required five intubations extending over a series of twenty-five days. The child made 
a splendid recovery. Such cases in private practice must be invariably supervised 
by a trained nurse. In this particular case careful feeding in addition to competent 
nursing was the means of saving the child's life. 



gE^Btgjglj^MEMEMEME i!!^ 




Fig. 183. — Laryngeal Diphtheria. Child 4 years old; mentally deficient. 
Seen in consultation with Dr. C. Hoffmann. (Original.) 



Constant cough or laryngitis lasting many months was encountered in 
4 cases of my series. All in all, there is no case in my series in which a 
distinct bronchial or laryngeal catarrh could be traced to or associated with 
the intubation. 



INTUBATION. 565 

Rogers says : "As regards the etiology of postdiphtheritic stenosis of 
the larynx and retained intubation tubes, the views of the late Dr. O'Dwyer 
are, of course, worthy of the greatest consideration. Nevertheless, I believe 
they are wrong. He maintained that the condition was the fault either of 
the operator or of the instruments, which means careless or unskilled inser- 
tion, or the use of poorly constructed, and, therefore, improperly fitting 
tubes. Formerly, while he was experimenting with and perfecting his in- 
strument, he sometimes encountered ulcerations and granulations; and the 
2 cases he reports of granulations at the base of the epiglottis, where it 
impinged upon the head of the tube, might properly be counted in this class. 
At all events there is no other record of a similar occurrence from the use of 
the hard-rubber tube as at present made. It must be admitted, no wevei, that 
erosions and ulcerations are possible with a metal tube, as its surface soon 
becomes rough from a deposit of what is apparently calcareous matter. 
But whether ulcerations and subsequent cicatrices may not be thus produced 
has very little to do with the matter, as they do riot seem to be the usual 
cause of the stenosis in the reported cases. . . . And it is important, 
from a medico-legal aspect, as well as for the sake of intubation, to show that 
neither the operator nor tube, ordinarily, has anything to do with a possible 
postdiphtheritic stenosis. It is granted that lacerations and serious per- 
manent damage to the larynx can, of course, be inflicted by extreme lack of 
skill or care ; but to claim that this must have happened in all, or even some, 
of the cases of retained tube is not borne out by the facts. A certain amount 
of traumatism is necessarily inflicted at every intubation; and if, by any 
chance, a chronic stenosis follows, the traumatism is always blamed for it. 
That this is wrong, at least in the average case, is proved to my mind by the 
pathology of the condition. It is the same whether the stenosis follows intu- 
bation or a primary tracheotomy." 

Causes of Recurring Stenosis. — Emil Kohl, in his inaugural address at 
Zurich, in 188^, described very fully the pathological condition of the 
larynx in cases of chronic postdiphtheritic stenosis with retained tracheal 
cannula. This article demonstrates most conclusively that not the least 
frequent cause of the difficulty is a chronic hypertrophic, subglottic 
laryngitis, a chronic thickening of the soft parts between the vocal cords and 
the lower border of the cricoid cartilage. The hypertrophy of the soft tissue 
was so marked that respiration, except through tracheal fistula, was impos- 
sible. These cases, of course, had never been intubated; and, therefore, 
the chronic inflammation within the larynx cannot be charged to the irrita- 
tion or traumatism consequent upon the insertion or wearing of an intuba- 
tion tube. 

^ Another and more frequent cause of the stenosis was shown to be 
granulations and cicatrices in the neighborhood of the tracheal wound or 
cannula. And the nearer the cannula was to the vocal cords the worse were 



566 THE INFECTIOUS DISEASES. 

these complications. The vicinity of the upper end of the wound was more 
prone to granulations and cicatrices than the lower, as the upper end gener- 
ally involved or was close to the larynx, where the mucous membrane is 
more loosely attached than below. This bears upon the cause of the stenosis 
described in some of the reported cases of retained tubes which have finally 
been tracheotomized. If the tracheotomy has existed long enough, it, and 
not the original intubation, may have given rise to the cicatricial tissue. 

Incidentally, it may be noted that the number of devices described by 
Kohl for remedying a postdiphtheritic stenosis will illustrate the difficulties 
in the way of successful treatment other than by intubation. 

In speaking of the operative treatment of stenosis of the larynx follow- 
ing intubation and tracheotomy, Arthur B. Duel says: "The important 
points to remember: (1) About 1 per cent, of all patients intubated for 
acute laryngeal stenosis will 'retain' the tube. (2) The cause of the reten- 
tion is due, in the majority of cases, to chronic inflammation of the intra- 
laryngeal mucous membrane and hypertrophy of the subglottic tissues, and 
is not, as has been generally supposed, the result of granulation, ulceration, 
or cicatricial bands. (3) Autoextubation in these cases is the rule, and 
adds greatly to the danger where an experienced intubator is not at hand. 
As a result of this a large number of such cases are tracheotomized for safety. 
(1) Where high tracheotomies are done, cicatricial bands are almost certain 
to form in the trachea or lower part of the larynx above the tracheotomy 
wounds." 

The points in treatment which should be emphasized are: (1) The 
largest sized tube possible should be inserted, under an anaesthetic. In case 
of contraction, rapid dilatation should be done by beginning with the small 
sizes and working up to the large special tube, which is to be left in place. 
This special tube should be as large as can be inserted, and the constriction 
below the neck only 1 / 32 inch smaller than the retaining swell. (2) This 
tube should be left in, undisturbed, for six weeks at least. It should then 
be removed, and, if a cure has not been accomplished, it should be replaced 
for six weeks longer. 

To illustrate the above the following case may be cited : — 

Child B., 2 years old, was seen by me in 1895, in consultation with Dr. 
McConville, of Brooklyn. The child had had a severe pharyngeal, tonsillar and 
laryngeal diphtheria. The temperature was 101° F., pulse 140, respiration labored. 
Child cyanotic. I intubated with a No. 2 metal tube, which immediately relieved 
the laryngeal stenosis. The general condition of the child improved greatly and 
three days later I was requested to extubate. Several minutes after extubation 
marked laryngeal stenosis recurred so that a second intubation was necessary. The 
child's condition again improved, and when normal conditions prevailed, in about 
four days I was again requested to extubate. Thus the child was intubated and 
extubated every four days for a month. As the family were unable to retain the 
services of a competent trained nurse, and as the child required frequent medical 



INTUBATION. 557 

supervision, the case was transferred to the Gouverneur Hospital. Dr. Rogers 
treated this case as he does all of his "retained tube" cases by introducing the 
largest sized tube that can be worn, and allowing the tube to remain in situ four, 
five or six weeks before extubating. After one month of this treatment I was 
informed that extubation permanently relieved the condition and the child was dis- 
charged from the hospital cured. 

Paralysis of the Vocal Cords. — Very many cases have been reported by 
competent observers on both, sides of the Atlantic. In America, Waxham, 
Kosenthal, Engelmann, myself and many others; in Europe, von Bokay, 
Trump, Egidi, Galatti, Massei, and Escat. 

Intubation in Hospital Practice. — There is a decided difference be- 
tween intubation in a hospital and intubation in private practice. In the 
Willard Parker Hospital, New York, there are always several physicians 
ready to intubate at a moment's notice. I have seen more than one case of 
mild stenosis treated with antitoxin and careful dietary get well without 
intubation. Haste is not necessary, and each case must be carefully 
treated. 

Intubation in Private Practice is an entirely different matter. Johann 
von Bokay in his review regarding intubation published in the "Transac- 
tions of the Section on Diseases of Children," held at Hamburg, 1901, 
honors me by the following quotation 1 : "Audi halte ich das Vorgehen 
von Louis Fischer, des hervorragenden intubates aus New York, fur 
unrichtig, der sagt: Ich mache es mir zur Eegel — wenn ich sicher den 
Nachweis liefern kann, dass es sich um eine Diphtherie handelt und ich das 
Vorhandensein des Klebs-Lofner-Bacillus contatirt habe, die intubation 
sofort vorzunehmen, wenn sich die geringste Stenose zeigt." 

While his statement is partly true, it does require a slight modification. 
When a mild case of laryngeal stenosis is encountered in private practice, 
then judgment must be used regarding the time for intubation. The 
points to be considered are: the distance at which the patient lives, the 
amount of diphtheritic infection that we are dealing with, and the circum- 
stances of the people in which the case occurs. If the child is fortunate 
enough to be under the observation of a competent nurse, who can recognize 
the slightest increase in the stenosis, watches the condition of the heart, and 
calls the physician the moment the slightest danger arises, then the condi- 
tions are most satisfactory and we can wait with intubation ; otherwise we are 
compelled to intubate when slight evidences of stenosis appear. I do not ad- 
vocate intubation the moment stenosis exists. In Case XXI of my series of 
private cases above reported, seen in consultation with Dr. Harry Weinstein, 



J My rule is to intubate when the slightest stenosis exists, provided the clinical 
diagnosis of diphtheria has been verified by the bacteriological diagnosis. 



5G8 THE INFECTIOUS DISEASES. 

the stenosis of the larynx was treated by an injection of antitoxin, the child 
placed under the care of a competent trained nurse with detailed instructions 
regarding progressive symptoms. Twelve hours later, when the stenosis in- 
creased in severity, I was summoned hurriedly to intubate. In this case the 
child wore the tube six days, and required but .one intubation to complete the 
cure of the stenosis. In America the majority of intubated cases occur in 
private practice. Von Bokaj states that according to Jacobi, only 5 per 
cent, of diphtheritic laryngeal stenosis are treated in the special (Willard 
Parker) hospital. The rest, 95 per cent., occur in private practice. 

The smooth rubber tube with or without metal lining is now generally 
used for the relief of laryngeal stenosis. Smooth rubber tubes, with a re- 
taining swell, the advantage of the same over the metal tube in not having 
calcareous deposits after being worn for weeks is certainly noteworthy. The 
corrugated rubber tubes which were introduced by me several years ago have 
certainly served me very well in many cases of "retained tube." 

The following case occurred in the practice of Dr. A. W. Newfield. The child 
was about 4 years old, and had suffered for several years with hypertrophied tonsils 
and adenoid vegetations, in addition to chronic pharyngitis. The family physician ad- 
vised the parents to have the throat operated owing to the danger of infection with 
diphtheria. This prophylactic measure was not carried out. I saw the case on the 
second day of illness, in consultation with Dr. Newfield, and found diphtheria in- 
volving the pharynx and tonsils which spread very rapidly to the larynx. The same 
day intubation was required to relieve a severe stenosis. The stenosis was so 
severe when I saw the child, and the pulse so weak, that it required a rapid intro- 
duction of the tube to afford relief. An. injection of 3000 units of antitoxin was 
given. Three days later a second injection of 3000 units was made; so that 6000 
units were injected in all. There was recurring stenosis when the tube was re- 
moved. It was necessary to intubate within ten minutes. . Extubation was per- 
formed once every five days, and reintubation was necessary a few minutes to one- 
half hour after removing the tube. Rubber tubes only were used in this case. After 
the second intubation an alum gelatine film was Used on the tube. 

After the third intubation it was deemed necessary to use a corrugated tube 
dipped in a solution of hot gelatine containing 3 per cent, of ichthyol and alum. 
This tube was worn about five days. After the extubation the child breathed well 
for about one hour without a tube. A mild form of stenosis was noticed and it 
was deemed safe to reintubate with an ichthyol alum gelatine film on a, No. 4 corru- 
gated rubber tube. This tube remained about six days and was then removed. 
Stenosis did not recur and the case was discharged cured. Later on the adenoids 
and hypertrophied tonsils were removed and the child has been well since. 

Conclusion. — All the children in both these series that recovered had 
been breast-fed. This form of feeding" must have had an important bearing 
on their bony development as well as their muscular structure. 

No chronic cough which could be attributed to the wearing of the tube 
was encountered. It was presumed by me at the outset of my investigation, 
that I might meet with a series of cases of chronic laryngitis, chronic 
tracheitis and chronic bronchitis, dating back to the intubation. We know 



INTUBATION. 569 

• 

that pressure of the tube has frequently caused decubitus; hence, it is pre- 
sumed that an inflammatory process might be invited from the wearing of 
the tube. Comparing an equal number of children of the same age and 
development who never suffered with diphtheria, nor were intubated, it was 
found that they suffered with pneumonia and other infectious diseases in the 
same proportion as children in my series of cases. This would seem to be 
a splendid argument in favor of intubation, as it shows two important 
points : — 

First. — The tolerance of the larynx to a tube for many weeks, one of 
my cases having worn a tube twenty-six days, another case twenty-five days. 

Second. — That a properly fitting tube constructed of rubber leaves no 
evidence of chronic inflammation directly traceable to the tube. In every 
one of my cases I questioned carefully if any catarrh originated from, or 
could be associated with, the wearing or removal of the tube, and .received 
negative replies. 

Equally interesting was it to study the contour of the thorax and to 
see if the development of the thorax suffered by reason of these children 
wearing tubes. 

In spite of the fact that the large majority in the first series as well as 
in the second were decidedly rachitic, no deformity of the chest due to imper- 
fect oxygenization could be attributed to the effects of the intubation tube. 
An etiological factor and one on which a great deal of stress has already 
been laid, is that 90 per cent, in my first series of cases suffered with chronic 
throat disease in some form, such as hypertrophied tonsils, chronic pharyn- 
gitis, or adenoids. In some all of the above conditions were apparent. 

It is safe to presume that chronic throat disease invites infection, and I 
believe that there is a direct relationship between the seed and the soil. If 
children's throats are in a normal condition, then the risk of infection is 
reduced to a minimum. It is our duty, therefore, to urge all mothers to 
have diseased conditions removed, and thus try to prevent the infection of 
diphtheria, which is certainly a serious condition. 

Becurring Laryngeal Stenosis Following Intubation 
and Decubitus. 

Etiology. — This condition is primarily caused by forcibly pushing a 
tube into an cedematous or infiltrated mucous membrane. O'Dwyer says 
that it is caused by using a tube that is too large for the lumen of the 
larynx; usually in the hands of inexperienced operators. Metallic tubes 
that have been worn for a long time contain large calcareous deposits — the 
latter are due to a deposit of lime salts contained in the diphtheritic mem- 
brane — and when removing such a tube during extubation, the mucous mem- 
brane is easily lacerated, and thus ulceration is caused thereby. One of the 
most important papers given to the profession was read by the late 



570 THE INFECTIOUS DISEASES. 

Joseph O'Dwyer. 1 In his paper entitled "Ketained Intubation Tubes" he 
says: "The cause of persistent stenosis following intubation in laryngeal 
diphtheria can be summed up in the single word 'traumatism/ Paralysis 
of the vocal cord may possibly furnish an occasional exception to this rule." 

Thus an injury to the larynx can be done by a tube that does not fit; 
it may result from an imperfectly constructed tube, or from a perfect tube 
that is too large for the lumen of the larynx, although proper for the age, 
or from a tube that is perfect in fit and make if not cleaned at proper inter- 
vals. O'Dwyer states that the seat of the lesion that keeps up the stenosis 
is j ust below the vocal cords in the sub-glottic division of the larynx, or that 
portion of the organ bounded by the cricoid cartilage. Exceptions to this 
rule result from injury produced by the head of the tube on either side of 
the base of the epiglottis, just above the ventricular bands. The reasons 
given by O'Dwyer for the existence of the stenosis at this particular portion 
can best be explained by the following:— 

Pathology. — Anatomically, normally, there exists a constriction in the 
cricoid region. When the mucous membrane infiltrates or gets cedematous 
it swells to such an extent and only toward the center, as the outside is sur- 
rounded by cricoid cartilage; and while swelling toward the center, me- 
chanically impedes respiration and thus calls for mechanical relief, i.e., intu- 
bation. O'Dwyer states that if a tube is forced into the larynx in a case of 
this kind, ulceration and sloughing of the tissues is inevitable, and in some 
instances necrosis of the cricoid cartilage can result from interference with 
the circulation. Our only safeguard in preventing too much mechanical 
injury as in the condition above cited is to introduce "a tube of small 
caliber." 

In the early stage of this form of cases the dyspnoea returns slowly; 
sometimes several days, or in some instances only a few hours, may pass 
before the former condition of laryngeal stenosis is recognized and the neces- 
sity for the introduction of a proper tube is demanded. 

When the dyspnoea returns slowly, it means that the lining membrane 
of the larynx cannot swell while the tube is in position because it is com- 
pressed between the tube and the cartilage. It requires some time for the re- 
appearance of the cedematous tissue, which drops into the chink of the 
glottis and obstructs the respiration, the latter condition being mechanically 
prevented as long as the tube was in situ. Exceptional cases have been re- 
ported where granulation tissue springs up from the antero-lateral aspects of 
the larynx just above the ventricular bands. O'Dwyer states that the 
origin of this growth is a slight ulceration or erosion of the mucous mem- 
brane at the points corresponding to the greatest transverse diameter of the 
shoulder of the tube from the pressure exerted during the act of swallowing. 

Paralysis of the Vocal Cords, although known to exist, is very hard to 

1 American Pediatric Society, at Washington, May 6, 1897. 



INTUBATION. 



571 



diagnosticate without a proper laryngoscopic examination. Like other 
forms of paralysis it comes very late in the course of the disease, and if, 
after wearing an intubation tube for a short time, laryngeal stenosis recurs, 
it is safe to assume that paralysis of the vocal cords is not the cause of the 
immediately recurring stenosis. 




Fig. 184. — Case seen in consultation with Dr. S. M. Landsmann, 
Diphtheria. Laryngeal stenosis requiring intubation. Normal conditions 
and extubation on the fifth day. Two days later, on the seventh day of 
illness, a sudden high fever, due to over-feeding, required diet and calomel. 
Case recovered. (Original.) 



False Passage. — Eepeated forcible attempts at intubation will lacerate 
the tissues. It is not infrequent to enter the ventricles of the larynx, pro- 
ducing a false passage by such forcible attempts at intubation. If a false 
passage has been produced, then laryngeal stenosis will not be relieved, and 
it is much wiser, if an expert intubator cannot be found, to immediately 
resort to tracheotomy. The great danger of collapse due to heart failure 



572 



THE INFECTIOUS DISEASES. 



must always be remembered; hence it is advisable that the operation, be it 
intubation or tracheotomy, should be done quickly, thus lessening shock. 

EXTUBATION. 

How to Extubate. — First step in the operation : place gag in position ; 
locate the tube with the left index finger; guide the extractor along the 



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Fig. 185. — Temperature Chart from a Case of Laryngeal Diphtheria. 
Excellent Result of Intubation and Antitoxin. Doubtful Prognosis. Re- 
covery. (Original.) 

finger until the beak enters the lumen of the tube. Second step in the oper- 
ation: depress the handle of the extractor to hold tube firmly, and with- 
draw the tube slowly. (See Plate XXVI.) 

.When to Extubate. — Five days is a fair length of time for the tube 
to be left in the larynx. The following rules have served me best in a 
very large experience in hospital and private practice: — 

Let the child's condition be the guide as to when to extubate. My 
advice is to leave the tube in the' larynx at least four days, then remove the 
same. 



EXTUBATION. 573 

The question to be considered is, Can the child undergo the shock of 
extubation, and, if need be, reintubation ? 

If the temperature is over 100° F., and the pulse-rate is small, rapid, 
and over 120, it is better to wait with the extubation. 

A rubber tube left in the larynx does not have calcareous deposits as 
we find them on the metal tubes; hence there is no danger in leaving a 
rubber tube in situ for several weeks. 

If the tube is plugged with mucus or membrane it may be necessary to 
remove the tube and clean it. A rattling or crowing sound in addition to 
laryngeal stenosis usually indicates this condition. 

At the Willard Parker Hospital there is no definite rule as to the 
number of days a tube remains in the larynx. Individual conditions 
govern the time of extubation. In some cases tubes are removed after 
forty-eight hours. The severity of the cases admitted to the hospital and 
the complication must be taken into consideration. Uncomplicated cases 
may be extubated any time between the third and seventh days when the 
oedema of the larynx subsides. In a few instances the child expels the tube, 
without having recurring stenosis. This auto-extubation is occasionally 
seen; it is Nature's method of removing a foreign body after the subsidence 
of the inflammatory condition. 

Choice Between Intubation and Tracheotomy. 

In cases where operation is indicated it may be said that intubation has 
steadily grown in favor, and its advantages, when it is indicated, are so 
obvious as to require no recapitulation here. On the other hand, conditions 
are sometimes present that render intubation impracticable or inadmissible, 
or at least render tracheotomy preferable. It is therefore desirable to 
keep clearly in mind the factors that determine the choice in favor of 
one or the other of these operations. This subject has received con- 
sideration in a study, by Drs. George Alsberg and Sigmund Hermann, of the 
cases of diphtheria, to the number of 4033, observed at the Kaiser und 
Kaiserin Friedrich Kinderkrankenhaus, in Berlin, for the ten years from 
1891 to 1900. As a result of this analysis it is concluded that operative in- 
tervention in cases of stenosis of the larynx of slight and moderate degree 
should be obviated as far as possible by means of antitoxin and the employ- 
ment of sprays. Primary intubation is indicated in all cases of stenosis of 
the larynx of severe degree in which, so far as the clinical picture makes it 
appear possible, a cutting operation can be avoided. Primary tracheotomy 
is indicated in the presence of asphyxia and collapse, of pneumonia, of severe 
heart disease, of paralysis of the palate and diaphragm, of profound ana- 
tomic changes in the pharynx, as well as marked tumefaction of the entire 
pharyngeal structures when necrotic. 



574 THE INFECTIOUS DISEASES. 

Secondary Tracheotomy is indicated when the symptoms of stenosis 
persist in marked degree with the tube in place, providing its lumen is not 
occluded, when pneumonia supervenes, and when paralysis of the palate 
and diaphragm supervenes. Intubation is not recommended in nursing in- 
fants by some writers on account of the diminutiveness of the parts and of 
the narrow lumen of the pharynx, but especially on account of the increased 
difficulty in feeding from the presence of the tube, which at this time of 
life is of vital importance. My personal experience is just the reverse, and 
my results have been excellent. 1 

Tracheotomy (In Acute or Subacute Laryngeal Stenosis). 

If laryngeal stenosis persists in spite of intubation, then secondary 
tracheotomy is indicated. When extensive oedema of the larynx exists, in 
which case intubation fails to relieve, tracheotomy may be required. I have 
frequently met surgeons who were well posted on tracheotomy, but were not 
familiar with the delicate modus operandi of intubation. 

If laryngeal stenosis threatens life, and the physician is not acquainted 
with the method of intubation, then by all means perform tracheotomy, 
rather than risk "experimental intubation." 

When emergencies arise they should be met by quick action. An in- 
teresting case of suffocation due to laryngeal stenosis was told to me by 
my friend, Dr. George F. Shrady : — • 

A child suffering with croup suddenly collapsed and was thought dead, when 
Dr. Shrady, in the emergency, took a razor which was handy and made an incision 
into the trachea. He used a bent hairpin instead of a tracheal dilator. The child 
breathed as soon as oxygen was admitted. The case recovered. 

Tracheotomies Performed {Willard Parker Hospital, 1911) with Bay of Disease and 
Number of Days Tracheotomy Tube Remained in the Larynx. 

Total number of tracheotomies performed 4 

Tracheotomized on first day of disease 3 

Tracheotomized on second day of disease 1 

Tracheotomy tube remained in larynx one day 1 

Tracheotomy tube remained in larynx two days 2 

Tracheotomy tube remained in larynx four days 1 

Result, 3 deaths; 1 recovery. 

Tracheotomies performed before admission 2 

The Operation. — Ancesthetic: If time permits, a few drops of chloro- 
form should be given. If septic stupor exists then no anaesthetic should be 
given. 

The high operation, "tracheotomie superieure," in which the incision is 



x See case of Baby R. in the practice of Dr. Kahrs, "Intubation in Private 
Practice." 



TRACHEOTOMY. 575 

made in the upper portion of the trachea, is preferred to the lower operation, 
advised by Trousseau, known as "tracheotomie inferieure." 

The upper portion of the trachea is quite superficial and it is best to 
make an incision, exactly in the median line, at least two inches in length. 
It is important to remember that the branches of the inferior thyroid veins 
are immediately under the place chosen for the operation; hence the parts 
must be carefully dissected with a blunt instrument, such as the back of a 
scalpel, until the trachea is reached. If there is severe bleeding the veins 
should be seized with a forceps unless emergency demands rapidity of action. 
The dissection should be continued until the trachea is reached. When there 
is considerable oozing of blood, and our view is thus obstructed, we must 
remember to keep in the center of the throat, which invariably brings us to 
the rings of the trachea. By placing the finger in the wound we will 
feel the respiratory movement of the trachea. When the trachea is reached 




S. TKIHANH * ca 




Fig. 186. — Silver Trachea Cannula 

used in tracheotomy. Fig. 187. — Hard-rubber Trachea Cannula. 

it should be hooked up with a tenaculum and an incision made large 
enough to admit the tracheotomy tube. The rush of air, so-called tubal 
sound, characteristic of intubation is also heard when tracheotomy is 
properly performed. 

After-effects of the Tracheotomy Tube. — The presence of the tube in 
the trachea invariably excites cough. This expels loose membranes and 
other viscid accumulations. High fever sometimes follows this operation, 
although as a rule the temperature will only reach 101° or 102° F. 

The pulse-rate should be carefully observed; a gradually increasing 
pulse-rate during the first three days after the operation is a very bad sign. 

Complications. — Broncho-pneumonia and nephritis are to be feared, for 
they frequently terminate fatally. The treatment of complications is the 
same as though the disease existed independent of the operation. 

After-treatment. — Careful aseptic methods must be the rule from the 
moment the child's stenosis is relieved. The infection of the wound will 
always be an added source of danger. As the majority of cases of trache- 
otomy will be performed for extensive pseudo-membranous stenosis, we must 
remember that septic diphtheria per se may cause death independent of the 



576 THE INFECTIOUS DISEASES. 

added danger incident to the opening of the trachea. All oozing of blood 
must be checked; pressure with sterile gauze saturated with Monsell's solu- 
tion has served me well. I have also used gauze dusted with a powder con- 
sisting of: — • 

IJ Europhen . . . . 7 parts 

Alum 3 parts 

To Check Hemorrhage. — The local application of adrenalin solution, 
1 to 5000, is very valuable during the operation. 

The internal cannula should be removed and cleansed every two or three 
hours, wiped dry and replaced. In rare instances it may be necessary to 
cleanse the cannula less frequently. This can best be determined by 
watching the respirations and instructing the trained nurse as to when the 
caliber of the tube requires cleansing. Noisy, rattling sounds due to the 
presence of mucus in the tube do not necessarily mean that the cleansing of 
the cannula is urgent, if the child is quiet or asleep. If the child is restless 
and turns its head from side to side, and usually mucous rattling is heard in 
addition, then it is an indication for cleansing the tube. 

Cleansing the Wound. — Each day following a tracheotomy, it is advisa- 
ble to place the child on the operating table, withdraw the tracheotomy tube 
and replace it with a new one. 

A writer states that "after the second or third removal the larynx 
should be examined to see if it is free and there is no further use for the 
cannula." My experience with tracheotomized cases has not been as good as 
that, for rarely have I seen a tracheal cannula that could be dispensed with, 
although antitoxin was administered, in less than seven to twenty-one days. 
The severity of my cases may account for the difference in experience. At 
times, in spite of the greatest amount of care, even in the hands of experi- 
enced operators, cicatrices of the trachea resulting in permanent contraction 
or exuberant granulations at the site of incision will require the continued 
use of the tracheotomy tube, as in cases described in the article on "Intuba- 
tion," known as "retained-tube cases." 



CHAPTER VII. 
RUBELLA (ROTHELN, GERMAN MEASLES, FALSE MEASLES). 

Rubella is an exanthematous eruption simulating measles. Oorlett's 
description of rubella is so classic that I give it word for word. 1 

"Rubella is a mild form of infection which always follows a benignant 
course and first appears as a general or constitutional disease, accompanied 
by a slight rise of temperature and slight feeling of illness. In this it 
conforms to the other affections of this class. 

"The local manifestations, while partaking of the character of those 
observed in both scarlet fever and measles, are distinct, and possess an 
individuality which, as a rule, may be recognized by the trained eye. 

"Etiology. — While we have no exact knowledge of the cause of the 
disease and in what respect the virus differs from that of other diseases to 
which it bears the closest resemblance, yet we do know that it is contagious, 
and always gives rise to a like disease: in short, conforms to the type. 

"It occurs but once in the individual, from which we infer that it is 
self-protective, while it affords no protection to or modification of measles 
or scarlatina; nor has it appeared that they offer any protection against 
rubella. It must be remembered, moreover, that even mild forms of the 
various exanthemata are self -protective. The fact that the patient has had 
at some previous time either scarlet fever or measles, or both of these 
affections in a well-marked degree, often leads to its recognition. Some- 
times, even before, its true nature has been definitely settled in the mind 
of the medical attendant, the disease disappears. 

"Like the other exanthemata, it always appears in the form of an 
epidemic, which seems to bear little or no relation to epidemics of other 
diseases, such as scarlet fever or measles." 

Bacteriology and Pathology. — Owing to the mild character of the dis- 
ease, the pathological changes have not been studied. There are certain 
changes seen in the skin, described by Thomas. Nothing definite, however, 
can be stated. Bacteria in the blood of children suffering with rubella have 
been described by several authors; these are by no means pathognomonic 
of this condition. 

"It sometimes occurs independently; again, two or more of the epi- 
demic exanthemata prevail at the same time. It must be admitted that ex- 
traneous conditions of weather and possibly of sanitation predispose in a 
like degree to all. Though epidemics of rubella seem to occur at less fre- 
quent intervals than do those of either scarlatina or measles, there can be no 
doubt that very many epidemics of rubella escape recognition, and are re- 



1 For a very minute description of this disease the reader is referred to Corlett's 
'Treatise on the Acute Exanthemata." Published by F. A. Davis Company. 

37 (577) 



578 ' THE INFECTIOUS DISEASES. 

garded as mild or aberrant forms of one or the other of the first-named 
affections. While the author believes, with Atkinson, that unless more 
exact methods are adopted in the study of the exanthemata there is still 
danger of endless confusion, and that the practice of relegating all mild or 
otherwise anomalous forms of measles or scarlatina to rubella is, as it was 
thirteen years ago, far too prevalent; yet the remedy lies in giving to this 
important group of affections a more conspicuous position than it now holds 
in the curriculum of clinical instruction." 

The period of incubation is usually from fifteen to eighteen days. 

In New York City cases. of rubella are excluded from school for one 
week, at the end of which time they will be readmitted on a medical certifi- 
cate. Children in the family who have had the disease may remain in 
school. 

Symptoms and Diagnosis. — The symptoms may be so mild that they 
are frequently overlooked. The prodromal symptoms appear a few hours 
before the rash is seen. Some authors state that in the majority of cases 
they are wholly absent. I have frequently seen catarrhal symptoms such 
as coryza, in addition to suffusion of the eyes, on the day previous to the 
eruption. 

Throat symptoms, such as congestion and swelling of the tonsils and 
fauces, are usually seen. Cough and hoarseness may also be present. The 
buccal mucous membrane does not have an enanthem. Forchheimer 1 
describes what he considers a characteristic enanthem in rubella which 
appears simultaneously with the exanthem and remains from 12 to 14 
hours. Its favorite location is on the soft palate, sometimes extending to 
the hard palate. It consists of small, discrete, dark-red but not dusky 
papules, which soon disappear, leaving no trace behind. The rest of the 
mouth may or. may not be congested. 

Sometimes there is anorexia and occasionally nausea or vomiting. J. 
Lewis Smith describes convulsions seen in the disease. The temperature 
varies between 100° and 101° P., rarely higher. The tongue is not as 
thickly coated as in measles, although the papillae may be enlarged. These 
projecting papillae appear on the tip of the tongue. The characteristic 
strawberry tongue is absent. 

Sneezing may be present and coryza may be absent, or vice versa. 

Thierfelder 2 states that "swelling of the subauricular and superior jugu- 
lar lymphatic glands may be looked upon as a constant prodromal symptom." 
Atkinson 3 says "enlargement of the superficial lymphatic glands of the neck 
may be the most striking symptom, and sometimes attracts attention several 
days before the beginning of the eruption." 



1 "German Measles," Twentieth Century Practice of Medicine, New York, 1898. 
% Thierfelder : Greifsw. Med. Beitr., B. ii, Ber., p. 14, 1864. 
"Atkinson (loc. cit., p. 23). 



RUBELLA. 579 

Corlett 1 says "his cases show adenopathy in 96 per cent, of which the 
maxillary and superficial or post-cervical were the most frequently in- 
volved; next the occipital, posterior and anterior auricular; and sometimes 
the superficial inguinal, axillary, and the epitrochlear. In the neck the 
inflammation may be sufficiently severe to interfere with free movement, and 
in two or three instances it has given rise to marked oedema of the sur- 
rounding parts." Suppuration of the glands is never observed. The 
lymphatic ganglia are also involved in the regions affected. The spleen is 
seldom involved. 

Pauline M., 6 years old, was brought to my office in an apparently good con- 
dition. I was told that the child had a rash on her chest and back, and that the 
temperature was 100° F. in the rectum. There was sneezing, but no cough nor 
bronchial symptoms. There was an enlargement of the glands on both sides of the 
neck along the posterior border of the sterno-mastoid muscle. The buccal mucous 
membrane, pharynx, and tonsils were but slightly inflamed. The conjunctivae were 
of a deep pink color. The rash was scattered over the abdomen and chest and was 
crescentic in its arrangement, similar to that seen in measles. The highest tempera- 
ture reached was 101° F., in the evening, pulse was 100, and the respiration 24. The 
treatment consisted in giving a mild laxative and liquid diet. Strict isolation was 
insisted upon. The eruption remained about three days. The child recovered 
without any complication. 

The Eruption. — The rash is first seen on the lace and scalp. It is 
described as "faint pinkish macula?, at first discrete, but sometimes becoming 
more or less confluent within a few hours." The eruption spreads down- 
ward to the neck and upper part of the abdomen until the upper and lower 
extremities are covered. The palms and soles are usually associated in this 
general eruption. The eruption reaches its full development after one or two 
days. It spreads slowly and fades on the face when it is about reaching its 
height on the lower extremities. Hardaway believes that this dissimilarity 
in the appearance of the eruption is a valuable means of distinguishing ru- 
bella from measles. "The individual lesions are sometimes perceptibly ele- 
vated and vary in size from a pin-head to a small bean." They are often 
slightly elongated or irregularly round in shape, with an ill-defined border, 
and disappear completely on pressure. Unlike measles, they show no 
tendency to form groups, clusters, or crescents, and in some cases manifest 
a feebler predilection to coalesce. Sometimes, however, when confluent they 
extend at the periphery, coalesce, and form extensive areas, when the re- 
semblance to scarJatina may lead to an error in diagnosis. 

"Usually the plaques thus formed are found only on certain parts, while 
on the remaining portions of the body the eruption presents the more usual 
appearance. The color is always lighter than that observed in scarlet 



1 Corlett, "A Treatise on the Acute Infectious Exanthemata," p. 356. 



580 



THE INFECTIOUS DISEASES. 



fever, and in a strong light the slight elevations which correspond to the 
original lesions may be discerned. Further, the eruption is fairly uniform 
in color and may be described as of a faded rose, or pink tint, never, in my 
experience, presenting the fiery red of scarlatina nor the dusky, bluish red of 
measles." 

Subjective Symptoms. — These are usually so mild that children do not 
complain. I have seen cases of rubella in the Kaiser and Kaiserin Frederick 
Hospital, in Berlin, while making rounds with Professor Baginsky, which 
were of a very mild nature and in which hardly any subjective symptoms 
were complained of. 

The Fever. — A peculiarity of this condition is that the fever does not 
correspond with the eruption, in intensity. Yon Nymann studied 119 cases 



DATE 


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Fig. 188. — Temperature Chart. Case of Rubella. (Original.) 



of rubella. He found that 58 cases showed no rise in temperature. In 
the remaining 61 cases the temperature was as follows: — 

In 39 cases the highest record was 100.4° F. (38.0° C.) 

In 14 cases the highest record was 101.3° F. (38.5° C.) 

In 6 cases the highest record was 102.2° F. (39.0° C.) 

In 2 cases the highest record was 103.1° F. (39.5° C.) 

Fever never remains more than four days unless some complication ex- 
ists. The pulse and respiration do not show much change, but usually cor- 
respond with the temperature. Sometimes a slight albuminuria is present. 

Desquamation. — A general desquamation is absent. Just as the rash 
spreads from place to place and is regional in character, so also is the 
desquamation regional. There is therefore no distinct stage of desquama- 
tion that can be applied to the disease as a who'e. 

Differential Diagnosis. — The following distinctive points are taken 
from Corlett: — 

"First. — That rubella is sometimes feebly contagious, while measles is 
always violently contagious. 



RUBELLA. 581 

"Second. — The prodromal stage is always short and quite insignificant 
in rubella, while in measles it continues from three to four days. 

"Third. — In measles the prodromal stage is usually accompanied by 
marked constitutional symptoms, with catarrh of the upper air passages, 
lacrymation, photophobia, and a more or less characteristic eruption in the 
mouth, which appears from twelve to forty-eight hours before the cutaneous 
exanthem. In rubella no characteristic prodromata are observed, and only 
at the beginning of the eruptive stage is there usually a slight hyperemia of 
the conjunctiva?, of the faucial mucous membrane, and rarely of the upper 
air passages. On the soft palate and uvula there is sometimes a punctate or 
faint macular enanthem, which by some is considered distinctive. Even in 
mild cases of measles the disturbance of the mucous membranes is more 
severe than in severe cases of rubella, and there is always, so far as I have 
observed, a bluish or skim-milk tint to the mucous membrane of the mouth, 
which I have never found in rubella. In rubella, sore throat is present in 
nearly all cases, while in measles sore throat is uncommon. 

"Fourth. — The eruption in rubella appears most frequently on the first 
and second day, rarely later. It often disappears from parts first attacked 
before other regions become involved. It is of a pale red or pinkish color, 
very rarely assuming a dusky tint, and the individual spots are surrounded by 
a faint areola, thus obscuring the outline of the lesion. The spots are 
papulo-macular, for the most part round or slightly oval in shape, and 
present no tendency to form crescents or groupings. Sometimes by 
coalescing they unite to form extensive areas, which in all cases, either at 
the periphery or on more remote parts, are associated with the discrete, small 
macules which give character to the eruption. The rash rarely lasts longer 
than three days, and most frequently it disappears on the upper part of the 
body on the second; while in measles the eruption almost always appears 
on the morning of the fourth day, sometimes on the third, and rarely 
earlier. In measles the color is of a dark or purplish red, and the lesions 
are well defined, with normal skin intervening. They enlarge at the 
periphery and show a marked tendency to form groups and crescents. These 
are especially marked on the face, neck, and upper part of the trunk. In 
all cases the individual lesions are larger than in rubella ; so that the whole 
surface of the body may be involved at the same time, consequently, it 
remains longer than that of rubella, lasting from four to five days, or longer, 
when defervescence begins. 

"Fifth. — In rubella the superficial lymphatic glands of the neck are 
nearly always involved, being swollen and sometimes painful; while in 
measles marked or painful enlargement of the glands of the neck is 
decidedly uncommon. 

"Sixth. — In rubella the temperature may be only slightly above the 
normal at any time during the course of the disease, and it rarely exceeds 



582 THE INFECTIOUS DISEASES. 

.102° F. (38.8° C). Nor is the temperature curve in any way characteristic 
of the affection. Further, it is usually of short duration and rarely contin- 
ues beyond the second or third day. In measles fever is always present and 
the temperature is sometimes high. There is an initial rise of temperature 
during the prodromal stage, which usually subsides, returning just previous 
to the appearance of the eruption, and attaining its maximum at the height 
of the efflorescence. The fever may continue until the seventh or eighth 
day. 

"Seventh. — Eubella is seldom accompanied by complications or fol- 
lowed by sequelae, while in measles complications are common and constitute 
the most serious feature of the disease." 

In studying the above we can readily see that measles is very frequently 
mistaken for rubella. Scarlet fever has a small punctate rash very uniform 
in character. The temperature, and the characteristic throat and tongue 
will usually differentiate this condition. 

Syphilis is frequently mistaken for rubella, but the absence of the 
characteristic initial lesion will aid in establishing the true diagnosis. Be- 
fore making a positive diagnosis we should see that our patient is not suffer- 
ing from a drug eruption. 

Complications. — These are rarely seen. The disease is so benign that it 
rarely leaves any after-effects. Eecurring rashes have been described by 
various authors, hence, a relapse is possible. This second rash does not 
differ in character from the first. The contagious nature of this condition 
has been well established. Hatfield reports 1 that of 196 children in an 
asylum, 110 were affected. Corlett believes that it is as contagious as 
measles, but the contagium retains its vitality longer and hence resembles 
scarlatina. The infectious nature of this disease has been studied by Ed- 
wards, who found that 75 per cent, of cases in an epidemic in Philadelphia 
could be traced to infection from the bunks of ships. 

Course. — Eubella runs a mild course. Cases seen by me during an 
epidemic in the winter of 1903-1904 remained ill about three to four days, 
rarely five days. Some authors state that children with rubella are ill one 
and two weeks. 

Prognosis. — This is always good. With good sanitary surroundings, 
aided by careful diet, recovery always takes place. 

Treatment. — A child with rubella should be put to bed and kept con- 
fined until all evidence of eruption has disappeared. A liquid diet should 
be prescribed. The gastro-intestinal tract must be watched ; the bowels and 
kidneys assisted if necessary. 



1 Chicago Medical Examiner, August, 1881. 



DUKE'S DISEASE. 583 



Duke's Disease (Fourth Disease). 

Many authors dispute the existence of a fourth disease, and maintain 
that abortive types of scarlet fever or abnormal types of rubella are the 
symptoms observed in so-called fourth disease. 

The existence of a separate exanthematous eruption has been brought 
before the profession many times. As early as 1885 Filatow, a Russian, 
outlined the symptoms of a fourth disease. 

The characteristic sjinptoms are an incubation period varying between 
nine and twenty-one days, thus resembling rubella. The eruption, according 
to Duke, is of an erythematous character and is seen on the face, especially 
involving the skin surrounding the mouth. There are no pharyngeal 
or tonsillar patches visible. The tongue does not show the characteristic 
strawberry appearance of scarlet fever. There is an absence of fever in 
most cases, and the active symptoms subside after two or three days. The 
lymph nodes in the neck, axilla, and inguinal region are palpably swollen. 
Following the eruption there is a fine, mealy desquamation. 



CHAPTER VIII. 
MEASLES (MORBILLI, RUBEOLA). 

Measles is an acute eruptive disease associated with fever. It is 
caused by the invasion of a specific micro-organism the character of which 
has not yet been definitely determined. 

Bacteriology. — Anderson and Goldberger have settled the question of 
the period of infectivity of the blood in measles. By inoculating monkeys 
with human blood from patients suffering with measles they find that the 
period of infection is greatest just before, and for about twenty-four hours 
after, the first appearance of the exanthem. At the end of about twenty-four 
hours from the first appearance of the eruption, the infectivity of the blood 
appeared greatly reduced and became progressively less thereafter. The 
virus of measles belongs to the ultra-microscopic group. Aronson and Som- 
merfeld found that the toxicity of the urine was increased in measles. 
Thus, if 2 c.c. of urine from a case of measles were injected intravenously 
into a guinea-pig, the pig died immediately with the symptoms of anaphy- 
lactic shock, or else became extremely ill. While this same toxicity can be 
found in children suffering with the fourth disease, and also with the 
serum disease, no such toxicity was found in urine from cases of scarlet 
fever, pertussis, typhoid, and tuberculosis. 

Aronson and Sommerfeld concluded from their experiments that the 
urine test will be a strong differential point in diagnosis between scarlet 
fever and measles. It would be important. to note that the virus has not 
been demonstrated in the mealy desquamation. 

Etiology. — Measles is a contagious and to a less extent an infectious 
disease. It is usually communicated direct from person to person. Inter- 
mediate contagion is comparatively rare. Contagion is possible three or 
four days before the rash appears on the skin, and continues until desquama- 
tion has ceased. Children differ as to their susceptibility, some contracting 
the disease by very short exposure, while others require a longer and more 
intimate contact. 

The disease can be more readily conveyed in poorly ventilated or 
crowded apartments, schools, and kindergartens, where many children are 
intimately associated. 

Period of Incubation. — The period of incubation ranges between nine 
and fourteen days, the average being eleven days. Some authors 1 give 
eighteen to twenty-one days as the period of incubation when measles occurs 
a second time. 



1 Graham: Article on "Measles," Morrow's "System of Dermatology," 1894, 
vol. iii. 

(584) 



PLATE XXVII 




Earliest Symptom of Measles. Can be seen several days before 
eruption on body appears. Characteristic bluish-white speck on a rose- 
colored background. Minute white dots separated from one another, 
best seen on inside of cheek. They are very dense near the teeth ; more 
discrete away from the teeth. Strong sunlight or reflected light will 
aid in locating them. 



MEASLES. 585 

In New York City cases of measles are excluded from school until five 
days after the appearance of the rash, at which, time, if he is otherwise well 
and all catarrhal discharges have ceased and the cough has disappeared, he 
may return. Children and other members of the family who have had the 
disease may continue in school, provided the quarantine at home is properly 
observed. Children and other members of the family who have not had the 
disease, and are immediately removed to another residence, may return to 
school at the end of fourteen days, the usual limit of the period of incubation. 

Pathology. — In a study of the early mucous lesions in the mouth 
Slawyk found that the epithelial cells were thickened and in some in- 
stances had undergone fatty degeneration. No specific micro-organism has 
been found in the lesions. Frequently there is a tendency to the formation 
of ulcers, which extends to the deeper parts. Unna called attention to the 
thrombosis of superficial vessels of the skin in a severe type of measles re- 
sembling smallpox. When gangrene existed, streptococci were always pres- 
ent. Corneil and Babes report a special form of pneumonia beginning as an 
interstitial pneumonia and later giving rise to a fibrinous effusion into the 
alveoli. It involves the lymphatic system, the interlobular and interalveolar 
tissue. 

The toxic effect of the measles virus resembles pathological changes 
noted in diphtheria. They can be found in the central nervous system. ]STo 
doubt, the toxin generated by a specific organism similar to that of the 
Loefner bacillus found in diphtheria causes the degenerative changes. 

Symptoms. — Prodromal Stage or Period of Invasion: The first symp- 
toms are those of an ordinary coryza, sneezing, dry cough, and watering 
of the eyes (lachrymation), with photophobia. Moderate fever, temperature 
from 101° to 102° F., rarely higher during the first day. There is some- 
times vomiting. 

This condition lasts about three days and is followed by the character- 
istic eruption. This eruption is first seen on the face or neck on the morning 
of the fourth day. Very young infants show extreme irritability and rest- 
lessness. The tongue is covered with a white fur. The papillae are red and 
swollen. They are hot as conspicuous as in scarlet fever. There is intense 
dryness and thirst, with marked anorexia, and usually constipation. 

The temperature shows great variability. Wunderlich, Thomas and 
von Jurgensen, who have studied the temperature exhaustively, state that it 
cannot be considered characteristic, owing to its frequent variations. The 
temperature, after having reached 102° or even 104° F., will on the second 
day of the disease drop to nearly normal. There is usually a morning re- 
mission to the temperature. The temperature in a characteristic case is 
sometimes deceptive, so that after three or four days of illness there may 
be a sudden activity of all symptoms with a rise of temperature. The tem- 
perature frequently reaches 105° F. 



586 THE INFECTIOUS DISEASES. 

Early Symptoms of Measles. — The absence of the thick epidermic cover- 
ing which masks the first pathological manifestations in the skin (exanthem) 
is more readily seen on the delicate mucous surfaces (enanthem). 

The enanthem in measles has long been known. It has been studied 
by Willan, in 1806; by Heim, in 1812; in Dunglison's "Cyclopaedia of 
Practical Medicine," in 1854; by Trousseau, in 1866. Niemeyer's "Prac- 
tice of Medicine," 1876, vol. ii, p. 528, mentions Eehn, who studied an erup- 
tion in the cheek, gums, lips, and fauces. Rilliet anel Barthez, 1854, and 
Monti, in 1873, devote considerable attention to the prodromal enanthem of 
measles. 

Flindt, of Denmark, describes it at length in the "Sundheds-collegium," 
as follows : — 

"First day of the fever : A slight, diffuse erythema of the throat. 

"Second day of the fever: A fairly dark redness without marked 
oedema of posterior pharyngo-palatine arch and tonsils, which on the 
anterior palatine arch (arcus glosso-palatinus) and velum palati is some- 
what less deep in color and of an irregularly diffused or mottled appearance. 
On the evening of the second day of the fever the mucous surfaces of the 
tonsils, and the posterior palatine arch, have undergone but little or no 
change, appearing as a uniformly red erythema, with slight oedema. On 
the anterior surface of the soft palate, and the posterior part of the hard 
palate, as well as occasionally on the remaining normal mucous surfaces, a 
distinct enanthema appears. The lesions are round or irregular in shape, of 
a bright-red color, having an ill-defined margin, with little or no elevation 
at this time above the surrounding surface. They range from a pin-head 
to a lentil in size, and occur singly, or are scattered irregularly over the 
surface. In places there is a tendency for the lesions to cluster in groups 
and to become blended. 

"They acquire a peculiar appearance on account of numerous small, 
white, glistening points (simulating minute vesicles), which occupy the 
middle of the small, red macules. These manifestations in the macules are 
irregularly grouped. One can see and feel the minute vesicles elevated above 
the surrounding areas. The palpebral conjunctiva is hypersemic in its 
entire extent. Besides the reticular and macular reddening of the con- 
junctiva, which is due to the disposition of the conjunctival vessels, there are 
also small, glistening, miliary elevations similar to the elevations in the 
palate. 

"Third day of the fever : The mucous surfaces of the buccal cavity, 
which up to this time have been only slightly hypersemic, are now found to 
be invaded by the lesions previously described. These latter are strongly 
marked over the entire anterior surface of the velum palati, the glosso- 
palatine arch, and usually also over the contiguous two-thirds of the hard 
palate. The red spots are sometimes very numerous, at other times isolated, 



MEASLES. 587 

and again, by blending, they form irregular figures of a stronger red than 
previously seen. Here and there a faint appearance of the previously 
described vesicle-like formations is seen projecting above the surrounding 
surface. On the other hand, they may also be found on the apparently 
normal mucous membrane. Similarly grouped spots with whitish vesicles 
now also appear on the inner surface of the cheeks, especially on the part 
opposite the juxtaposition of the upper and lower molar teeth. 

"As a rule, the gums and the inner surface of the lips retain their nor- 
mal color, or at most are only slightly hyperemia It is, indeed, seldom that 
the eruption appears on these parts. The tonsils and both pharyngo- 
palatine arches still remain red. 

"The palpebral conjunctiva retains its deep-red color, but no spots are 
visible, excepting the minute vesicles previously described. At this time 
the eruption breaks forth on the skin. On the evening of the third day 
there is little or no change perceptible. 

"Fourth day of the fever : On the palate and inner surface of the 
cheeks the spots stand out prominently, while in many places there is a 
tendency to merge by enlargement of the individual lesions, and on the 
surfaces last invaded they are more copious than ever. The conjunctival 
exanthem is now disappearing. On the evening of this day there is no 
change noted. 

"Fifth day of the fever : The exanthem in the buccal cavity is more 
marked than heretofore. Frequently at this time there appear faint-reddish 
spots on the mucous surfaces of the lips, even extending to the exposed 
cutaneous margin. On the gums they are seldom present and never distinct. 
The rrypersemia of the posterior fauces remains unchanged. The skin 
exanthem begins to fade, and the temperature falls. 

"Sixth day of the fever: The exanthem of the mucous surfaces is no 
longer visible, except a slight diffuse redness of the palate and the inner 
surface of the cheeks. Fever ends." 

This characteristic enanthem is seldom absent. Slawyk 1 found it 
present in 90 per cent, of all eases examined. 

Koplik described these symptoms 2 and to him belongs the credit of 
having popularized the enanthem. It is generally known as Koplik's sign. 
The spots are best seen on the inside of the cheeks opposite the molar 
teeth, although I have seen them very clearly defined on the mucous mem- 
brane of the upper lip corresponding to the incisors. 

The patient must be examined in a strong sunlight or with a good 
electric light. A yellow gaslight, for instance, is very unsatisfactory. 

Differential Value of this Sign. — This enanthem is of great value 
in differentiating measles from other exanthemata, notabty, however, from 



1 Slawyk: Deut. med. Woch., April 28, 1898. 

* Archives of Pediatrics, December, 1896: Medical Record, 1898. 



588 ™E INFECTIOUS DISEASES. 

antitoxin rashes, drug eruptions, and eruptions associated with toxaemia 
from gastric fevers. 

Period of Efflorescence (Eruptive Stage). — The eruption usually ap- 
pears on the fourth day of the disease. Sometimes it appears as early as the 
third and sometimes as late as the fifth day. The first spots appear on the 
forehead or the temples, behind the ears, and on the sides of the neck. 
Later, spots appear about the eyes, mouth, and chin. When the rash is at 
its height then a crescentic character, first described by Willan, will be 
noticed. The constitutional disturbances increase in severity. The cough 
is more pronounced and there is a decided interference with the respiration. 
Nosebleed is quite frequent. Constipation is usually followed by very loose 
bowels. 

The Hash. — The rash is of a dark-red, sometimes a purplish, color, of a 
round, oval or irregular shape. The skin between the rash remains intact, 
although the face has a puffy, cedematous appearance. The eruption extends 
over the trunk and extremities, including the palms and soles, the arms 
and legs, the forearms and legs being the last to become affected. 

When the rash reaches its height the constitutional symptoms subside. 
It is not infrequent to see a normal temperature two days after the rash has 
completely covered the body. In some instances there is a crisis, although 
the usual rule is for the temperature to fall gradually by lysis. A sub- 
normal temperature frequently follows and accompanies the period of con- 
valescence and until the patient is normal. 

The catarrhal symptoms continue to increase in severity with the devel- 
opment of the rash. 

There are moist rales heard on auscultation. The sputum as well as the 
nasal discharge becomes sero-purulent. A bronchitis or a pneumonia should 
be suspected, if the respiration is exaggerated. The pulse-respiration ratio 
will be found of great value in diagnosing latent pneumonia,. The urine 
will show the excess of urates, and sometimes transitory albuminuria or 
hyaline casts may be found. The diazo reaction is sometimes noted, but it 
does not teach us anything of value in either the diagnosis or prognosis. 
This stage of the disease rarely lasts more than from four to six days. 

Stage of Desquamation, or Convalescent Period. — The eruption on the 
skin of the face, neck, and upper part of the chest fades and there is a slight, 
branny desquamation. This is less marked than in scarlet fever, and is so 
fine on the trunk and extremities that it may be' unobserved. It is best seen 
on the sides of the nose, temples and chin. Large, flaky scales are rarely 
met with in measles. After the eruption disappears, a certain amount of 
pigment remains for a week or two where the rash existed. 

Atypical or Anomalous Conditions. — Certain symptoms of normal 
measles vary in different epidemics, although the majority of cases present 
distinct clinical features. Predisposing factors, such as rickets and scurvy, 



MEASLES. 589 

possibly tuberculosis, will frequently alter the type of the disease or 
modify the symptoms. Edgar 1 reports an epidemic of 423 cases in which 
123 adhered to the regular type. 

Abortive Type. — We occasionally see a child with catarrhal symptoms 
and an eruption lasting but one or two days, after which the child is as 
well as ever. Such cases will frequently baffle the physician because of the 
irregular course. These cases belong to the abortive type. 

Typhus Fever. — Typhus fever frequently resembles measles. There 
is an absence of the catarrhal symptoms common to measles. The eruption 
is more marked on the body, less marked on the face. In typhus there are 
severe nervous and cerebral manifestations which rarely exist in measles. 

In measles the eruption is macular or papular and arranged in irreg- 
ular, crescentic groups, and begins on the face. 

In typhus the eruption is rarely seen on the face and is petechial in 
character. 

Anaphylaxis. 2 — Morbilliform rashes frequently follow the ingestion of 
certain albuminous foods, so that some children will be covered with an 
eruption resembling measles when partaking of eggs or meat. Other chil- 
dren will have a severe eruption after an injection of horse-serum. This 
subject has been described in detail in the chapter on "Diphtheria." 

The characteristic feature of an anaphylactic reaction (morbilliform 
type) is the absence of the catarrhal symptoms. There is no conjunctivitis 
nor cough, which latter always accompanies true measles. 

The temperature rises the day preceding the eruption, and returns to 
normal on the appearance of the exanthem. 

Mild Forms. — Measles may be present without catarrhal symptoms. In 
such cases fever may be slight or absent. In other cases the catarrhal 
symptoms are severe, while the cutaneous exanthem is almost wholly absent 
(morbilli sine morbillis). Such cases might readily escape notice unless 
they partake of a series during an epidemic in which both the mild and 
the severe type are found. 

Relapsing Form, or Second Attack. — A relapse is said to occur in rare 
instances after the exanthem has disappeared. When the second rash 
appears there is a return of fever and also the other constitutional symp- 
toms. Eecurring measles is often a very serious matter, owing to the 
already weakened state resulting from the first invasion. 

Corlett doubts the so-called relapses and believes that they are due to 
a direct reintoxication by the specific virus. 

Severe or Malignant Forms. — Malignant measles is that form in which 
there is a very high fever, rapid pulse, labored breathing, and great prostra- 



1 Can. Med. Record, December, 1892. 
2 See "Anaphylaxis in Diphtheria." 



590 



THE INFECTIOUS DISEASES. 



tion. The fatal issue most frequently occurs on the second day of the 
exanthem. We frequently meet with a typhoidal or a toxic form in which 
the symptoms are of a most malignant character. The mouth becomes 
parched and the tongue brown and dry, resembling a typical typhoidal con- 
dition. 

The bowels are loose and the quantity of urine diminished. Convul- 
sions resulting from the general toxaemia are very common. It is usually 
fatal and rarely ends in recovery. Where there is severe respiratory dis- 
turbance, with difficult breathing, it is called the suffocative form. In this 
form we have principally cough and expectoration with severe dyspnoea. 

The patient is cyanotic. Mucous rales are heard early in the disease, 
and it not infrequently ends in a broncho-pneumonia. 

Hcemorrliagic forms, known as the black measles, are' frequently de- 
scribed. The mild form of hsemorrhagic measles has been described by 
various authors. Edgar reports 200 cases out of 423, or 47 per cent, of the 
hemorrhagic form. Holt found it in 5 per cent, of his cases. The cutane- 
ous exanthem assumes a dark bluish or purplish tint, which gradually deep- 



Table No. 59. — Showing 503 Cases of Measles and Complications, Treated in the Riverside 
Hospital, New York City, During the 3Ionths of January to July, Inclusive. 





No. of Cases. 


Uncompli- 
cated Measles. 


Measles 

and 

Diphtheria. 


Measles 

and 

Pneumonia. 


Measles, Scar- 
let Fever and 
Diphtheria. 


Measles and 
Scarlet Fever t 


1904 


Cases 


Deaths 


Cases 


Deaths 


Cases 


Deaths 


r- ases 


Deat.s 


Cases 


Deaths 


Cases 


Deaths 


Jan. 


34 


4 


31 


1 


2 


2 


1 


1 










Feb. 


70 


8 
14 


62 


1 


7 


6 


1 


1 










Mar. 


133 


111 


2 


9 


6 


4 


4 


2 


1 


7 


1 


Apr. 


103 


15 


84 





8 


8 


10 


7 


1 









May 


106 


16 


77 


2 


13 


4 


13 


8 


1 


1 


2 


1 


June 


37 


8 


23 





7 
3 


3 

1 


7 


5 










July 


20 


5 


12 





5 


4 










Total 

Cases 


503 




400 




49 




41 




4 




9 




Total 
Deaths 




70 




6 




30 




30 




2 




2 



MEASLES. 



591 



ens as the process continues, to a bluish-black color. Frequently the whole 
body shows a tendency to bleed. Thus the mucous surfaces are implicated, 
giving rise to epistaxis, bleeding from the gums, dysentery stools and 
haemorrhages from the genito-urinary tract. Where a tendency to haemor- 
rhage exists, as in hemophilic subjects (bleeders), they are especially predis- 
posed to the hemorrhagic form. 



160 



Date. 



MEMlE 



2 |3 1 4 I 5 I 6 1 7 



W*EM*E 



ME ME 



ME ME 



11 1 12 1 13 [14 115 1 16 1 iy 1 18 1 19 [20} 21 |22j23l24 




Fig. 189. — A Case of Malignant Measles, complicated by Diphtheria and 
ending with Empyema. Male child, 3 years old. Septic from beginning. 
Fatal termination. Seen in my service at Riverside Hospital, New York 
City. (Original.) 



Complications. — Pulmonary: There seems to be a predisposition to 
pulmonary disease, commencing with a bronchial catarrh, especially in those 
children with feeble resisting power. The inflammatory condition extends 
into the smaller ramifications of the bronchial tubes, causing capillary 
bronchitis. When this occurs it should be viewed with alarm. The child 
shows dyspnoea and adynamic symptoms, owing to difficult oxygenation. 



592 



THE INFECTIOUS DISEASES. 



The Larynx. — One of the most frequent and fatal complications met 
with in children is laryngitis. This may be : — 

(a) Spasmodic. 

(b) Phlegmonous. 

(c) Membranous. 

The last named complication is the one most frequently met with, espe- 
cially in institutions. It is most common during the eruptive stage as early 
as the third or fourth day. The symptoms are the same as those met with 
in laryngeal diphtheria accompanied by stenosis of the larynx. 

The Klebs-Loeffler bacillus is sometimes found on bacteriological ex- 
amination of the pseudo-membrane. It can be found in 6 to 10 per cent, of 
all cases of membranous laryngitis. 



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Fig. 190. — Temperature Chart from a Case of Measles Complicated by 
Broncho-pneumonia. Seen during my service at the Riverside Hospital, New 
York City. (Original.) 

Broncho-pneumonia. — This is the most frequent and the most fatal 
complication of measles. Houl 1 found it in one-fifth of all of his cases. In 
the Nursery and Child's Hospital of New York, Holt observed it in 40 per 
cent, of all cases. This infection can invariably be traced to the presence of 
various organisms of which the pneumococcus of Friedlander, and the 
micrococcus of Frankel play a conspicuous role. 

There is marked retraction of the chest in addition to the usual signs 
of pneumonia. The physical examination shows widely disseminated sub- 
crepitant rales which soon give way to definite resonance, bronchial breath- 
ing, and fine crepitations. In young children its onset is acute, with rapid 
pulmonary congestion, and it usually terminates fatally within two or three 

1 Wien. klin. Rund., 1897, vol. xi, p. 833. 



MEASLES. 



593 



days. When the condition extends over a more subacute course, it may lead 
to caseous pneumonia or pulmonary tuberculosis. 

Case I. Kate A., aged twenty-one months. Child was admitted to the Riverside 
Hospital August 25, 1904, in fairly good condition, with temperature 104° F., pulse 
136, respiration 36. Sick since August 22d. Child had a moderately severe cough on 
admission. On August 26th cough increased in severity, breathing short, rapid and 
labored. 

Physical examination showed only a few coarse rales at upper part of chest 
posteriorly, with slight dullness, but no bronchial breathing. 



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Fig. 191. — Temperature Chart from a Case of Measles Complicated by 
Broncho-pneumonia. Seen during my service at the Eiverside Hospital, 
New, York City. (Original.) 1 

Well-marked dullness over the right base posteriorly, with bronchial voice and 



chial breathing. 

On August 28th, pleuritic friction sounds over right base posteriorly. 

On August 31st, percussion gave marked dullness, almost flatness over this 
area, extending slightly above the inferior angle of right scapula. Over this area, 
marked bronchial voice and breathing. 



*I am indebted to Drs. Alfred Helgeson, Bruno Horwicz, and Win. Ogden Lord for 
clinical histories, charts, and statistics. 



594 THE INFECTIOUS DISEASES. 

On September 1st, bloody serum obtained upon aspiration. 

On September 3d, serum obtained by aspiration, bloody with slight turbidity. 
General condition continued the same up to September 9th. On this day a drop in 
the temperature from 102° to 97.6° F. occurred. Child appeared brighter, slept well 
and has a good appetite. 

During the last two days, fluctuations in temperature* have occurred, ranging 
from 98° to 101° F. (evening rise). 

This fluctuation of temperature continued up to September 14th. On this date 
there was an evening rise to 99° F. only, and since then, the highest rise has been 
99 3 /5° F. The pulse has improved much in quality. Respirations have gradually di- 
minished in frequency. The child was aspirated on the 13th, but no pus or serum 
was obtained. Dullness was diminished over right base posteriorly and bronchial 
breathing was present only over a small area at base of right lung. Child at present 
sits up, has good appetite, and sleeps well. 

Case II. L. Z., age eight months. Admitted to the Riverside Hospital on August 
29th, having been ill since the 21st. Upon admission showed characteristic symptoms 
of broncho-pneumonia with temperature 101.4° F., pulse, 150; respiration, 56. Upon 
examination, dullness was present over right base behind, with bronchial voice and 
breathing. Many coarse rales were heard over both lungs behind as well as in front. 
There was a pleuritic friction sound over the consolidated area. No signs of effusion. 
Child improved rapidly, and upon September 3d, the bronchial breathing had disap- 
peared and only signs were coarse rales over both bases behind. Recovery. 

Otitis Complicating Measles. 1 — A very frequent sequela is acute otitis. 
If, after several days of apparent convalescence the child is irritable, restless 
at night and feverish, and cries continuously, a careful examination of the 
ears should be made. As a rule our attention is first directed to this con- 
dition after the cavity of the middle ear is filled with the discharge, and 
there is a spontaneous discharge of pus. 

Siegfried Weiss 2 calls attention to the method of prophylaxis in this 
condition. He believes that with good care we can prevent and abort this 
complication. Tobeitz believes that in measles we are dealing with a pri- 
mary enanthematous disease of the middle ear. 

In a post-mortem study of 95 cases, pathological changes affecting the 
ear showed the destructive tendency due to the disease itself. 

Tobeitz found that 86 per cent, of fatal cases of measles showed ear com-- 
plications. Bezold in a study of 18 fatal cases of measles noted ear disease 
in 17, or about 95 per cent. Weiss studied 112 cases in which there were 
ear complications, and after careful prophylactic treatment he had only 6.6 
per cent, of ear complications. Weiss's prophylactic method consists in ap- 
plying a 1 per cent, yellow precipitate ointment on a sterile swab to the 
nostrils. By this method he removes the dried and fluid secretions from the 
nose mechanically. Another method of Weiss' consists in allowing 1 or 2 
drops of 1 / 2 per cent, nitrate of silver solution to drop into the nostril. In 



1 Read chapter on "Otitis." 

2 Wiener Medicinische Wochenschrift, No. 52, 1900. 



MEASLES. 



595 



this manner he believes we can destroy the specific infections material. 
Hayek has long advocated this method in the treatment of chronic rhinitis 
in children. In using the salve or the silver nitrate solution Weiss found 
that if it was applied three or four times a day, the percentage of compli- 
cations was greatly reduced. 



Table No. 60. — Measles Stat sties Showing 
Ear Complications, Riverside Hospital. 



1904. 


Number of 
Cases. 


Measles and 
Otitis. 


January 


31 


6 


February 


74 


11 


March 


127 


10 


April 


101 


14 


Total 


333 


41 



Empyema. — Empyema is occasionally met with during the course of 
measles. As there seems to be a decided tendency to suppurative formations, 
it is well to inspect the thorax and be sure that we can exclude empyema. 
This should be borne in mind if cough exists associated with fever. I have 
seen empyema complicating measles in about 2 per cent, of my cases. When 
the exploratory puncture shows pus the treatment is the same as that given in 
the chapter on "Empyema." 

The Eyes. — Severe inflammatory and destructive changes are met with 
in measles. Abscesses of the conjunctiva or keratitis, resulting in ulceration 
of the cornea, are sometimes seen. In other cases it may extend to the 
antrum or, if the mastoid cells are involved, it can result in meningitis, 
cerebral abscess, or pyaemia. In very young children the petromastoid 
suture, which at this time is still patent, allows free access of pus into the 
cranial cavity from the middle ear. Not infrequently this condition leads 
to actual deafness. 

Immunity. — One attack of measles usually confers immunity for life. 
Second attacks are, however, possible, and third attacks have also been re- 
ported as instances of rare conditions. 

Measles is rarely seen in infants under 1 year. Mayr observed that of 
10 nurslings exposed to measles, only one contracted the disease. I have 
rarely met with infectious diseases in healthy breast-fed infants. There 
seems to be some antitoxic property conveyed to the nursing infant through 
the serum contained in the breast-milk of its mother. 



596 THE INFECTIOUS DISEASES. 

At the Eiverside Hospital I have seen nursing infants, in the measles 
wards, that had been exposed and did not contract the disease. 

Immunity can be conveyed by a mother who has had measles, through 
her milk, but how long this immunity lasts remains still to be investigated. 

Diagnosis. — An ordinary cold with coryza, as met with in influenza, is 
sometimes confusing. Mistakes will occur unless we are careful to note the 
enanthem which is absent in influenza. The rise of temperature is less 
marked in influenza than in measles. 

The diazo reaction is sometimes observed in cases of measles. By its 
presence we cannot, however, diagnose measles. 

Drug Eruptions. — Some eruptions resembling measles are caused by 
quinine and antipyrin. The internal use of chloral is sometimes followed 
by an eruption. Cubebs and copaiba give an eruption simulating measles. 1 

Bites of insects, especially bedbugs, fleas, and mosquitoes, sometimes 
produce an eruption which resembles measles. As there is no febrile dis- 
turbance or any enanthem the differential diagnosis is easily made. The 
injection of antitoxin and antistreptococcic serum sometimes produces an 
eruption which is morbilliform in character. 

Course. — As a rule three weeks should elapse before a case of measles 
is permitted to return to healthy children. The quarantine should be ex- 
tended over this length of time. This applies to institutions as well as to 
private families. Isolation should be continued if a case suffers from any 
complication associated with the primary measles. In other words, measles 
otitis, measles vaginitis, or any other complication, requires isolation. 

Prognosis. — When reasonable care is taken, then this is one of the least 
fatal of infectious diseases. The vital point consists in guarding the patient 
against unnecessary exposures and attending to all functional disturbances. 
With proper attention to the diet and symptomatic treatment when neces- 
sary, there should be little or no trouble experienced. If the fever declines 
after the full development of the exanthem, the prognosis is good. 

If croup and diphtheria complicate measles, then the prognosis is al- 
ways grave. Broncho-pneumonia is usually fatal in one-third to one-half 
of all cases. Sometimes a broncho-pneumonia will be followed by tuber- 
culosis. Diarrhoea with or without bloody stools should always be looked 
upon as a serious complication. 

Treatment. — In the treatment of measles certain rules should in- 
variably be followed: — 

(a) Hygienic. 

(o) Dietetic. 

(c) Medicinal. 

Hygienic Treatment. — The temperature of the room should always be 



P. A. Morrow: "Drug Eruptions/' New York, 1887. 



MEASLES. 597 

uniform, no less than 68° F. and never more than 74° F. Modern clinicians 
assert that the former method in vogue, of bundling up the body and keeping 
the air of the room very hot, produces a certain amount of susceptibility to 
respiratory diseases. In this manner we invite complications rather than 
prevent them. The body of the child may be sponged with tepid or warm 
water, and fresh linen can be given every day. 

Overheated rooms cause more trouble during treatment of respiratory 
affections than any other factor. 

Light of the Room. — Careful observers have noted that the light in 
the room has absolutely nothing to do with the eyes. Owing to the in- 
flammatory state of the eyes, there is a normal photophobic condition. No 
one would think of putting a child in the beginning of measles in a 
glaring sunlight, but rather with its back to the light. At the measles pa- 
vilion in Berlin, under the supervision of Professor Baginsky, the hygienic 
conditions are perfect. Plenty of fresh air is admitted and also light. I 
have frequently had the pleasure of making rounds in the wards of this 
pavilion with Professor Baginsky, and noted the above-named conditions. 
We do not darken the windows in the measles wards at the Riverside Hos- 
pital of New York City, and the hygienic conditions regarding fresh air and 
fresh linen have been excellent during my term of service there. 

Dietetic Treatment. — We must not -forget that in all febrile conditions 
the digestive function is impaired. The diet must be so regulated that there 
is proper assimilation. If subnormal conditions prevail, we must order a 
smaller quantity of food and allow a longer interval between feedings. 

A baby receiving pure milk should receive one-half milk and one-half 
oatmeal water, and if it has been fed every three hours when in good health, 
then it is wise to try to feed every four or five hours during the febrile stage 
of measles. An important point to remember is that liquids are an im- 
portant part of the treatment. Soups, acidulated waters, and carbonated 
waters are grateful and indicated. Orangeade and lemonade are grateful, 
especially to relieve thirst. If the child is older and has been. fed on solid 
food when in health, then all solids should be discontinued and liquid food 
substituted. Water should be given in large quantities. 

Medicinal Treatment. — If the eruption is tardy in appearing then a 
mustard foot-bath, using a tablespoonful of mustard in a foot-tub of warm 
water, 100° F., and adding warm water gradually until the temperature is 
about 105° F., will frequently hasten the appearance of the rash. This is 
as hot as the child can stand it for a few minutes. If there is a general 
depression of the vital powers, then give spir. mindererus, a teaspoonful 
every hour, until perspiration is active. This will also frequently hasten 
the appearance of the rash. One of my favorite drugs is tincture of aconite, 
in 1-drop doses, if the fever is very high. 



598 THE INFECTIOUS DISEASES. 

Pneumonia requires the same care and treatment as if it were not a 
complication or a sequela to this disease. (See chapter on "Pneumonia.") 

Diphtheria calls for the same treatment as if it was not associated with 
measles. 

Immunity from Diphtheria. — An injection of 300 to 500 antitoxin 
units will confer immunity from diphtheria in a case of measles. 

The urine must be frequently examined for a possible nephritis and 
treated accordingly. 

Convulsions frequently usher in the disease and should be very care- 
fully attended by rest, sinapisms, enemata of chloral, and possibly a few 
leeches to the neck. 

Epistaxis is usually an early but passing symptom, but if persistent, 
it should be treated on general principles and the cause looked into. The 
congestion during an attack of measles has frequently excited an otherwise 
quiet polypus to activity and caused alarming haemorrhages. 

For the relief of the cough I usually give : — 

1$ Ammon. bromid 9 i j 3.00 

Syr. liquorit gj or 25.00 

Decoct, althffi ad 3ij 50.00 

M. Teaspoonful every hour, for a child 1 year old, until relieved. 

For a child 2 years old: — 

I£ Codeine 2 grains 

Sacch. alb 1 V 2 drachms 

M. Divide in chart No. X. Sig.: One powder every two hours until cough is 
relieved. 

Summary of Treatment. — Give the child excellent hygiene — fresh air — 
protect the body with clean linen. Guard against draughts. Isolate the 
patient. 

Do not give solid food; liquid diet only, soups, broths, milk, butter- 
milk if tolerated, etc. 

Do not give useless drugs. Treat symptoms, such as hyperpyrexia, 
constipation, suppression of urine, and assist the emunctories. The greatest 
part of the treatment is the management of convalescence — codliver-oil, iron, 
Fellows' compound syrup of hypophosphites, malt preparations, cereals, 
butter, eggs, and cream ; meat sparingly ; all green vegetables ; oranges and 
lemons. 

Health can be restored by cautious management during the stage of 
convalescence. When cough remains and symptoms point to the beginning 
of tuberculosis, we must not lose sight of the fact that more can be accom- 
plished by climatic treatment — out of doors, in the country — than by in- 
door treatment. Complete change of air, to a more even climate like 
Denver, Colo., New Mexico, or Florida, will frequently restore the lungs to 
their normal condition. 



CHAPTEE IX. 
SCARLET FEVER (SCARLATINA). 

Scarlet fever is an acute infectious, specific and contagions disease. 
This disease is usually ushered in by vomiting and sore throat, accompanied 
by fever. If the child is old enough it will complain of headaches. 

The pulse-rate will be accelerated, and there is usually on the second 
day a distinct eruption visible. This disease presents several types: the 
mildest form, known as scarlatina simplex or the benign form, and the 
most malignant type, scarlatina maligna, called by the French "fou- 
droyante." 

There are a great many varieties between the two types just men- 
tioned, so that any sharp differentiation is quite impossible. 

Of the many varieties, those most frequently met with are: First, 
mild; second, septic, and occasionally the hemorrhagic type is seen. 

Etiology. — It has been established beyond doubt that disease germs 
even though they might exist in desquamated cuticle die when exposed to 
the air. The theory of the transmission of scarlet fever by such means is 
wrong. That the disease is transmitted through the air has not been estab- 
lished. Personal contact is necessary. 

Infection by Contact. — In Paris, the Pasteur Hospital has demon- 
strated that infection in hospitals can be minimized by avoiding contact. 
Grancher, in Paris, employed wire screens around the beds to impress the 
nurses of the necessity for guarding against infection by contact. 

Scarlet Fever and Milk, — Hall, 1 in a very interesting article, found, 
after an extensive review of the literature, that, "while scarlet fever occurs 
in epidemic form in those countries where cows' milk forms a staple article 
of food, especially among children, it does not occur in countries where 
cows' milk is not used as a food, or where children are raised on mother's 
milk only." This is true of Japan, where cows' milk is not used and 
domestic animals are scarce, and it is true in India, also, where, though 
cows' milk is used, the children are nursed by their mothers until they are 
3 or 4 or even 6 years of age. 

While this immunity from scarlet fever, together with the absence 
of cows' milk as an article of food, may be simply a coincidence otherwise 
explainable, does it not suggest the possibility of infection through the 
gastro-intestinal tract as perhaps the chief source? 

Climate. — Epidemics are more common in America in the fall and 
winter than in the summer months, although I have seen malignant cases 



X H. O. Hall: New York Medical Record, November 11, 1899, p. 698. 

(599) 



600 



THE INFECTIOUS DISEASES. 



both in hospital and private practice just as bad in midsummer as in mid- 
winter. We know by clinical experience that the poison of scarlet fever is 
less volatile than that of measles, and is not transmitted any great distance 
through the atmosphere (Hall). 

Table No. 61. — Scarlet Fever Cases Occurring in Children Under 18 Years. 
Willard Parker Hospital. 































CO 




































o3 




03 
0) 


CO 

S-i 
03 
CD 


03 

a> 


03 
CD 


03 




03 


a 


e3 


03 

OJ 

n 


03 

CD 








u 


t» 


|H 


>H 


fH 


>H 


X 


5* 




<N 


IC 


00 






a 


-a 


O 


O 


o 


id 
O 


to 
o 


O 


CO 

o 


o 


O 


o 


o 






O 


P 


- 


CM 


CO 


43 


iO 


+3 

to 


c~ 


00 


O 


<N 


lO 




Male 


870 


7 


39 


80 


105 


76 


90 


87 


87 


113 


65 


69 


52 


1910 


Female 


914 


11 


40 


82 


93 


81 


109 


92 


80 


126 


84 


78 


38 




Total 


1784 


18 


79 


162 


198 


157 


199 


179 


167 


239 


149 


147 


90 




Male 


705 


9 


28 


60 


65 


72 


84 


90 


45 


69 


104 


38 


41 


1911 


Female 


947 


9 


58 


75 


100 


90 


110 


99 


90 


160 


37 


59 


60 




Total 


1652 


18 


86 


135 


165 


162 


194 


189 


135 


229 


141 


97 


101 



Age. — The greater number of cases occur between the ages of 5 and 10 ; 
next in frequency, 2 to 5. Then the frequency gradually diminishes. 

Stage of Incubation. — Authorities differ as to the length of time that 
usually elapses between the exposure to the disease and the appearance 
of sjanptoms. The usual rule is from a few days to a week, although 
exceptions will extend the time to several days longer. 

Eichhorst and von Leube give it from four to seven days. Individual 
susceptibility plays an important part in scarlet fever as well, as we have 
seen in other diseases. 

Henoch maintains that we cannot form an idea of the severity or 
mildness of an attack by the early symptoms. 



Table No. 62. — Statistics of Cases of Scarlet Fever Treated in the 
Riverside Hospital, New York City. 



Ye.r. 


Number of 
Cases. 


Deaths. 


Mortality 
Per cent. 


1903 

1904, Jan. to Oct. 


835 

718 


76 
46 


9.1 
6.4 



Bacteriology. — The distinct specific cause of scarlet fever is unknown, 
in spite of immense scientific work. A specific micro-organism first de- 
scribed by Class 1 is a non-capsulated diplococcus, appearing occasionally in 



x New York Medical Record, September, 1899, p. 330. 



SCARLET FEVER. 

a 



601 




Fig. 192. — a, "Inclusion Bodies," case of Scarlet Fever. A, Neutro- 
phil granules, "b, "Inclusion Bodies," case of Scarlet Fever following ex- 
tensive burns of the body. {Kolmer.) 



602 • THE INFECTIOUS DISEASES. 

Table No. 63. — Scarlet Fever Cases Treated at Willard Parker Hospital. 

1910 1911 1912 

Number of cases treated 2302 1984 2127 

Total number of deaths 247 211 179 

Percentage mortality 10.7 10.6 08.41 

Total number dying within 24 hours 19 

Percentage mortality 0.8 

Total number dying within 48 hours 36 38 27 

Percentage mortality 01.5 01.9 01.2 

streptococcic form, polymorphous in character. It is constantly found in 
the pharynx in scarlatinal angina. 

Baginsky and Sommerfeld 1 found a streptodiplococcus in the pharynx 
and blood in scarlet fever which they believe to be the etiological factor in 
that disease. As yet scarlet fever cannot be reproduced in animals, and 
hence this microbe must be looked upon as the probable causative factor. 
Owing to the immense amount of research work being done, the day is not 
far distant when the specific factor of all infectious diseases will be 
discovered. 

Pathology. — The gross and histological lesions found post-mortem in 
scarlet fever depend essentially upon two processes : first, the action of the 
scarlatinal toxin, associated with the changes seen in any acute febrile dis- 
ease; and, secondly, they may occur as a result of a mixed infection due to 
entrance into the organism of the streptococcus pyogenes, the staphylococcus 
pyogenes aureus or albus, the pneumococeus, and, rarely, other micro-organ- 
isms. So long as the specific agent concerned in the scarlatinal infection 
remains obscure, it must be impossible — in many instances at least — 
to determine, in a given case, which of these two elements is the predomi- 
nant one. In cases succumbing early in their course to the intensity of the 
poison, before the development of secondary infections, we must assume 
the changes present to be due to the specific scarlatinal virus, while in those 
which prove fatal later, associated with grave throat lesions, streptococcic 
angina, etc., the possibility of an added etiological element in the lesions 
present after death must be admitted (Corlett). 

The Blood. — The diagnostic importance of inclusion bodies in scarlet 
fever has been confirmed by many observers. A true scarlet fever can fre- 
quently be determined by the presence or absence of the inclusion bodies. 
Thus, the absence of the inclusion bodies means serum exanthem and not 
scarlet fever. 

Inclusion Bodies. — Inclusion bodies were described by Dohle in 1911. 
These bodies are found within the cytoplasm of the polymorphonuclear 
leucocytes. Since then Kretschmer, in Berlin, and Mcholl and Williams, 
in New York, have not only confirmed these findings, but lay stress on 



Berlin, klin. Woch., No. 22, 1900, p. 588. 



SCARLET FEVER. 603 

the diagnostic value of these bodies in scarlet fever. These bodies occur 
early in the disease, usually during the first five days of the infection. A 
simple blood smear on a clean slide and stained by Giemsa or Wright and 
Jenner method will bring them out. Kolmer reports 30 cases of serum 
sickness showing urticarial rashes ten days after admission to the Philadel- 
phia Hospital; not one showed the presence of inclusion bodies. Twelve 
cases of measles were examined and all were negative; 1 case of rotheln, 
negative. Of eleven cases of erysipelas examined inclusion bodies were pres- 
ent in 7. Inclusion bodies seem to be present not only in scarlet fever, but 
also in other streptococcus infections. In diphtheria inclusion bodies are 
frequently noted. As a rule, in the early stages of a rash following an in- 
jection of antitoxin the absence of the inclusion bodies speaks in favor of 
serum exanthem and against scarlet fever. 

Bowie 1 reports 167 cases with a total number of 714 counts. 
Of these, 77 were differential to determine the relative percentage of the 
three main varieties of leucocytes. The following is the summary of his 
conclusions : — 

1. Practically all cases of scarlet fever show leucocytosis. 

2. The leucocytosis begins in the incubation period, very shortly after 
infection ; reaches its maximum at or shortly after the height or severity of 
the disease, and then gradually sinks to normal. 

3. In simple, uncomplicated cases the maximum is reached during the 
first week, and the normal generally some time durirjg the first three weeks. 

4. The more severe the case the higher is the leucocytosis, and the 
longer it lasts; the milder the case the slighter the leucocytosis, and the 
shorter time it lasts. 

5. A favorable case of any variety of the disease has always a higher 
leucocytosis than an unfavorable one of the same variety. 

6. The temperature has no effect on the leucocytosis. 

7. The polymorphonuclear leucocytes are increased relatively and abso- 
lutely at first, and then fall to the normal, the lymphocytes acting inversely 
to this. This cycle of events occurs in simple cases within three weeks. 

8. Eosinophiles are diminished at the onset of the fever. They in- 
crease rapidly in simple favorable cases till the height of the disease is past, 
then diminish, and finally reach the normal some time after the sum total 
leucocytosis has disappeared — in short, when the poison has all been elimi- 
nated. 

9. The more severe the case the longer are the eosinophiles subnormal 
before they rise again. In fatal cases they never rise, but sink rapidly 
toward zero. 



1 Reported in Berlin, klin. Woehenschrift. (No. 31, 1897.) 






604 TH E INFECTIOUS DISEASES. 

10. The leucocytes, in complications, go through a cycle of events 
similar in all respects to that of the primary fever as regards both sum 
total and differential leucocytosis, and the same laws govern the behavior of 
the leucocytes in both cases. 

In regard to the diagnosis of scarlet fever, the simple counting of the 
leucocytes gives little aid. A differential count, however, may be of aid, 
for scarlet fever is one of the few acute infectious diseases where one finds 
an increase in the eosinophiles early in the disease and the persistence of 
that increase for some time. 

With regard to prognosis, the examination of the leucocytes seems 
likely to be of some practical value. In scarlatina simplex, if the case be 
severe, and the leucocytosis be high and rising, one may predict a favorable 
course ; and conversely, if it be low and stationary, one may expect a tedious 
case. Eegarding the differential count, if the eosinophiles show a relative 
increase, the augury is good; if they are normal or subnormal after the first 
day or two, then the case will in all probability be a severe one. Further- 
more, as long as a relative increase of eosinophiles is present one cannot be 
sure that some complication will not ensue; whereas, if the eosinophiles 
have come down to normal in the usual way, one may be free from anxiety 
in this respect. 

Symptoms. — The onset is usually very sudden. In young children the 
attack is preceded by a convulsion. Vomiting is an early symptom. 

Tongue. — The tongue has a whitish fur and the papillse will be found 
elevated and very red. It has the so-called "strawberry" appearance (see 
Plate XXVIII). The throat, especially the tonsils, will , be found intensely 
congested and dry. Sometimes a severe diarrhoea is the first symptom. 
The pulse is full and rapid, from 120 to 140 beats per minute. . The tem- 
perature on the first or second day is about 102° F., rarely higher. 

Glands. — Enlarged inguinal glands are a characteristic feature of this 
disease. The submaxillary lymphatic glands at the angle of the jaw are 
swollen and tender on palpation. The mucous membrane of the mouth is 
reddened. The pharynx, tonsils, and the uvula are injected. Monti 1 calls 
attention to an enanthem in scarlet fever which is seen late on the first day 
or early on the second. It is a diffused, mottled reddening, which begins 
upon the uvula, spreads quickly over the hard and soft palate, covering the 
pillars of the fauces, and finally the mucous membrane of the cheeks. 

The Urine. — There is febrile albuminuria present, which disappears 
as the temperature declines. The urine is scanty and high-colored. 

The Rash. — This appears usually within the first twenty-four hours. 
It is first seen upon the neck and chest — less often upon the small of the 
back. It is a bright-scarlet pin-point flush, and occupies the sites of the 
hair follicles. The rash extends from above downward, spreading in a 

1 Jahrb. f. Kindh., vol. vii, p. 227. 



PLATE XXVIII 




Strawberry Tongue in Scarlet Fever. Painted from a case in the Riverside 
Hospital. The body rash is shown in the Frontispiece. (Original.) 




Beefy Tongue in Scarlet Fever. The tongue has a glazed appearance. 
The papillae are enlarged. This type is usually seen when desquamation 
begins, after the rash has faded. Painted at the bedside from a case in the 
Riverside Ho pital. (Original.) 



SCARLET FEVER. 



605 



few hours to the arms; usually in twenty-four hours it reaches the trunk, 
legs, and abdomen. (Study frontispiece.) A point to note is that in con- 
trast to measles and smallpox it is much less marked upon the face and 
cheeks. The immediate neighborhood of the nose and mouth remains free 
from the eruption and has a peculiar pallor, a marked contrast to the 
parts affected by the eruption. The dorsal surfaces of the hands and feet 
show the eruption. The palmar and plantar surfaces, though frequently 
injected, do not usually show the true punctate scarlatina rash. 

The rash shows great variations. While it may show large or small, 
faintly scarlet colored patches lasting but a short time, the opposite more 



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Fig. 193. — Septic Scarlet Fever with Myocarditis, Suppurative 
Arthritis, Double Purulent Otitis, General Pyaemia. Case seen in consulta- 
tion in private practice. Child 4 years old. (Original.) 



frequently occurs. When it is diffuse it may be of an intense scarlet or 
almost purple color. (See frontispiece.) It frequently shows a tendency 
to stain the tissues, and minute haemorrhages may occur with the formation 
of petechias. 

Septic Scarlet Fever. — This type is most commonly met with in chil- 
dren. The symptoms are of a more severe type. There is high and con- 
tinued fever, with involvement of the pharynx and tonsils. Prostration is 
the vital symptom, showing the evidence of severe infection. There are 
marked cerebral symptoms, such as extreme restlessness, convulsions, or mild 
delirium. In this type we usually have persistent vomiting associated with 
general apathy. The fever rises suddenly to 105° F., or 40.5° C, or higher. 
The pulse becomes very small and rapid, from 140 to 160 per minute, al- 
though at times 200 per minute. The thirst is extreme, the tongue is dry 
and gums parched. The throat, especially the tonsil, is deeply injected 



606 TH E INFECTIOUS DISEASES. 

and frequently has scattered foci of exudate on the surfaces. The urine is 
concentrated, and invariably contains albumin. 

Hemorrhagic. — This is the most malignant form and is very rare. 
The disease. is very abrupt in its onset. The temperature reaches 105° to 
107° F., and sometimes higher, within the first few hours. 

The pulse is greatly accelerated and is weak and intermittent. The 
cheeks and lips are blanched and may show cyanosis very early. The urine 
is scanty, high-colored, and albuminous, or may be completely suppressed. 
There are marked cerebral disturbances, such as convulsions and active 
delirium. Frequently we have marked dyspnoea, the respiratory rhythm 
being short and quick, due usually not to any change in the lungs at this 
time, but probably to irritation of the respiratory centers, according to 
Ausset. Ataxic and adynamic forms are characterized by early and pro- 
found constitutional depression, due to the effect of the toxin on the nerve 
centers, the symptoms rapidly assuming a typhoidal type. 

In the hemorrhagic forms the exanthem acquires a dark-purplish hue. 
Small petechias, varying in size from a pin-head to a lentil, appear scat- 
tered irregularly over the body. The blood oozes from the gums, the sputum 
even being tinged with it, while epistaxis may be severe. Blood may be 
discharged from the bowels or the stools may be tarry in color. 

Bleeding is frequently seen from the genito-urinary tract or the urine 
shows the presence of blood. This form of disease is usually encountered in 
very feeble infants under 2 years of age and is invariably fatal. 

Scarlatina Sine Exanthemata. — Cases frequently occur in which every 
evidence of scarlet fever exists, but there is no eruption. Henoch states 
that he believes the eruption is always present and thinks that it is occa- 
sionally overlooked. The eruption is frequently of such an evanescent char- 
acter that it entirely escapes notice, but a subsequent desquamation and 
nephritis will usually strengthen the diagnosis. 

A case of scarlatina sine exanthemata was seen by me in the family of Dr. J. 
Lurie, of New York City. A child about 4 years old had been in apparent health. 
There was no history of vomiting nor any gastric disturbances. No history of ex- 
posure to scarlet fever. When examined by me I found no evidences of scarlet 
fever. The throat was somewhat congested, but had no patches, nor was there any 
evidences of necrotic membrane visible in any portion of the throat. The lymphatic 
glands of the neck were not enlarged. The urine was very scanty and contained 
more than 50 per cent, by volume of albumin. Blood was also present in large 
quantity. There were also hyaline, epithelial, and granular casts present when a 
drop was examined under the microscope. 

The child's urine was greatly diminished in quantity, hardly a tablespoonful 
being passed at one sitting. Diuretin and citrate of potash acted very well as 
diuretics, and later the secretion of urine was normal in both quality and quantity. 
At times it seemed as though the urine consisted of pure blood. Later the child 
developed an otitis media, which was preceded by a rise in temperature. The child 
made a good convalescence and is perfectly well to-day. 



PLATE XXIX 




Scarlet Fever. Willard Parker Hospital. 

1. Furfuraceous Desquamation. 2. Circinate Desquamation. 
3. Flaky Desquamation. 

(Courtesy of Dr. Howard Fox.) 



SCARLET FEVER. 



607 



Scarlatina Papulosa. — Small, slightly elevated papules of a dark-red 
color develop at the site of the hair follicles. They are more readily de- 
tected by the finger than by the eye, and are observed twelve to eighteen 
hours before the ordinary scarlatinal rash appears. 

Scarlatina Variegata. — This form is marked by an extremely irregular 
distribution of the eruption, frequently associated with the development of 
well-defined macular areas of an intense red color, situated at the site of the 
hair follicles, and in many instances simulating the exanthem of measles. 

Scarlatina Sine Febre. — Among extremely mild cases of scarlatina in- 
stances are frequently seen in which, after a slight initial rise, the disease 




Fig. 194. — Unusually Severe Desquamation. 

(Original.) 



Willard Parker Hospital. 



progresses without any subsequent elevation of temperature above 98.5° to 
99° F., every other symptom being present, but in a mild degree. 

Henoch reports 4 cases out of 175 with irregularities of temperature. 
Fever of an inverted type has been reported by Henoch, who noted the tem- 
perature curve quite the reverse of normal, in which the temperature was 
higher in the morning than in the evening. 

Scarlatina Sine Angina. — This form of scarlatina has very slight throat 
symptoms or so insignificant as to appear almost absent. A slight conges- 
tion of the throat is visible, and usually a faint enanthem is present early 
in the disease. 

The tonsils are not enlarged, but there is an almost constant enlarge- 
ment of the papillce at the tip and edges of the tongue — an important diag- 
nostic aid. 

Desquamation. — The desquamation of the skin in scarlatina begins 
over those areas on which the rash was first seen, namely, the thorax and 



608 THE INFECTIOUS DISEASES. 

neck. Thus, we will frequently find evidences of desquamation on one part, 
while another part of the body has distinct traces of the rash. 

Character of the Desquamation. — On the neck, face, and trunk the 
epidermis peels off in fine, flaky scales. This is known as desquamatio 
furfuracea. This is similar to the desquamation found in measles. The 
extremities, about the hands and feet, show the characteristic desquamation. 
The epidermis peels off or can be stripped off in shreds of varying lengths. 
This is known as desquamatio membranacea or lamellosa. 

Duration of Desquamation. — This varies greatly and is influenced by 
the severity of the infection and the intensity of the eruption. It persists 
longest where the epidermis is thick, namely, about the hands and feet. At 
times it will be necessary to soak the hands and feet, then rub them with 
pumice stone to hasten the removal of the epidermis. 

The length of time for complete desquamation may be from six to 
eight weeks. It may be of a shorter or longer duration. Eepeated des- 
quamation is not uncommon, so that we can say there is secondary and, less 
frequently, tertiary desquamation. 

Complications. — Scarlatina with Other Exanthemata: Mixed infec- 
tions are frequently noted. Measles, chicken-pox, or smallpox are met with. 
Corlett depicts a case of scarlatina with chicken-pox. 

Mixed infections have been seen many times during my service in the 
scarlet fever wards of the Eiverside Hospital — scarlet fever and whooping- 
cough, scarlet fever and measles very often, scarlet fever and diphtheria as 
well. 

The Throat. — Scarlatina is usually seen very early in the pharynx and 
fauces. This takes place whether we are dealing with a mild or severe in- 
fection. We know that certain pathogenic bacteria, such as streptococci, are 
invariably found during the course of scarlatina. 1 

Many bacteriologists agree that the Klebs-Loeffler bacillus is usually 
absent, though there are many cases of true diphtheria complicating scarlet 
fever. Several cases of diphtheritic angina have been seen by me while on 
service at the scarlet fever wards of the Eiverside Hospital. Lemoine found 
the streptococcus pyogenes in 93 cases out of 117 studied by him. The 
Klebs-Loeffler bacillus was found in addition in 5 cases of this series, and 
the bacillus coli communis in 9 cases. 

Angina Pseudomembranosa (of Streptococcic Origin). — False mem- 
branes upon the tonsils or pharynx are seen in the severe and septic types 
of this disease. It is simply a necrotic inflammatory deposit. On the second 
day the mucous membrane of the pharynx is intensely reddened and con- 
gested. The tonsils, which are much inflamed and swollen, show scattered. 



1 See elaborate clinical and bacteriological studies made by Baginsky and 
Sornmerfeld, in Arehiv fur Kinderheilkunde, 1900, and Berlin, klin. Woeh., No. 22, 
1900, p. 588. 



SCARLET FEVER. 



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fever. From Author's service at the Riverside Hospital. 



39 



610 THE INFECTIOUS DISEASES. 

irregular patches of gray or grayish-white exudate, completely occluding the 
tonsillar crypts over a more or less limited surface. One or both tonsils 
may be affected. In many instances the pharyngeal inflammation from the 
beginning shows an extreme grade of intensity. This may spread over the 
posterior pharyngeal wall, the hard palate, and the mucous membrane of 
the posterior surface of the cheek; also, to the posterior nares and the 
Eustachian tube, with resulting extension of the inflammatory process to 
the middle ear. There is a very foul odor to the breath, and usually a thin, 
acrid secretion from the nostrils, causing excoriation, fissures, and, rarely, 
rhagades. 

The nostrils may be occluded and the mouth held open in an attempt 
to breathe. 

Angina Scarlatina Membranosa (of True Diphtheritic Origin). — This 
should be regarded as a true diphtheritic complication and treated as diph- 
theria (see chapter on "Diphtheria"). 

Otitis. — The extension of the infection from the pharynx through the 
Eustachian tubes has already been mentioned. As a rule, the younger .the 
child, the greater the danger of otitis. According to Bader and Gruinon, the 
mild or catarrhal form occurs in 33 per cent, of all cases of scarlet fever, 
and the purulent form is less common, occurring in 4.5 per cent, of all 
cases. 

Caiger, reporting 4015 cases of scarlet fever, noted ear discharge in 
11.05 per cent. In a series of 397 cases observed by me, including severe, 
malignant, and all complicated varieties, there were 82 middle-ear dis- 
charges, 68 purulent and 14 catarrhal. 

About 20 per cent, of all cases seen by me had middle-ear trouble. It 
is important to have the middle ear examined when high fever persists 
during an attack of scarlet fever. Persistent high fever in a case of scarlet 
fever occurred in my private practice. It was also seen by Dr. J. W. 
Brannan and by Dr. Dench. After an examination of the middle ear, a 
thorough incision of the drum membrane liberated pus and relieved the 
temperature for a time. 

The hand will frequently be carried to the head or ear. The neigh- 
boring lymphatic glands are enlarged, palpable, and may be tender. After 
a few days, unless relieved by incision, the tympanic membrane ruptures 
spontaneously. The symptoms then usually subside. When, however, the 
inflammation becomes purulent (otitis media suppurativa), then the con- 
dition is serious, owing to the possibility of deafness arising. 

Empyema of the mastoid antrum, 1 resulting from chronic suppurative 
otitis media, occurs in a small percentage of cases. With the establishment 
of a communication between the tympanic cavity and the cells of the mas- 
toid, there is usually a slight decrease in the amount of discharge from the 



x Read article on mastoid (chapter on "Otitis"), page 815. 



SCARLET FEVER. 611 

Table No. 64.— Complications in Scarlet Fever. Willard Parker Hospital. 

Year 1910 1911 1912 

Number of cases 2302 1984 2127 

Eye Complications. 

Conjunctivitis (purulent) 86 68 1 

Conjunctivitis (gonorrhoea]) 14 13 3 

Conjunctivitis (catarrhal) 28 142 84 

Eae Complications. 

Mastoiditis (operative) 14 25 

Mastoiditis (non-operative) 8 37 25 

Otorrhoea (purulent) 180 194 249 

Otorrhcea (diphtheritic) 5 14 

Throat Complications. 

Positive throat cultures on admission 358 33 117 

Requiring intubation 11 7 74 

Intubation cases recovered 8 

Tonsillitis 89 74 

Regurgitation 27 22 

Adenitis (cervical) 512 274 120 

Cardiac Complications. 

Endocarditis 32 61 49 

Myocarditis 29 41 56 

Pericarditis (with effusion) 2 5 1 

Pericarditis (fibrinous) 3 4 3 

Bradycardia 25 16 

Irregularity 125 369 

Nephritic Complications. 

Albuminuria 391 357 281 

Nephritis (marked) 53 34 51 

Uremic convulsions 11 9 8 

General Complications. 

Arthritis 85 145 148 

Delirium 17 95 72 

Erysipelas 11 1 11 

Pneumonia 34 160 114 

Empyema 4 3 4 

Measles 86 94 

Typhoid on admission 4 3 1 

Antitoxin rashes 

Morbilliform 10 21 

Searlatiniform 38 15 

Urticarial 30 45 

Erythema multiforme ... 47 27 



612 THE INFECTIOUS DISEASES. 

ear. The temperature rises to 104° F., or higher, and shows a marked 
fluctuation of a remittent character. There may be rigors. If old enough 
the child will complain of pain in the mastoid region with tenderness on 
palpation over the mastoid process. 

The pulse becomes rapid and irregular. These symptoms continue from 
day to day, and unless an operation is performed these cases will end fatally, 
due to the development of meningitis. 

More rarely an inflammatory swelling appears behind the external 
ear — situated over the mastoid — associated with a rise of temperature, local 
tenderness, with more or less forward projection of the ear, and occasionally 
local suppuration, with abscess formation, takes place. 

Mastoid Infections. — The virulence of the streptococcus and the pneu- 
mococcus must always be remembered. In addition to the streptococcus, 
some cases will show the presence of the staphylococcus. In one of my cases 
seen recently, we encountered an almost pure culture of bacillus pyocyaneus. 
This latter condition is extremely rare. 

These bacteria always accompany both the severe and mild forms of 
infection and predominate in the nose and throat. The proximity of the 
Eustachian tube permits these bacteria to penetrate into the deeper struc- 
tures and thus reach the mastoid. It is therefore important to have in mind 
the ease with which a middle-ear disease may begin. 

When fever persists, daily inspection of the ear should be made. If 
the temperature rises and the child shows discomfort and pain, and there is 
the slightest bulging or redness of the tympanic membrane, no time should 
be- lost, but an incision made. 

Many cases of otitis will yield promptly when the drum is incised and 
pus drainage established. When tenderness exists over the mastoid, an ice- 
bag or a cold-water coil will afford relief. 

After the incision of the tympanic membrane warm saline irrigations, 
three times a day, are indicated. This will clean away all the discharge, and 
prevent the incision from closing. When thick, tenacious discharge is pres- 
ent which cannot be washed, away, it must be wiped away by means of an 
applicator mounted with dry absorbent cotton. While some otologists ad- 
vise plugging the ear with absorbent cotton, I have had better results by 
allowing free drainage. 

A case of this kind occurred in the private practice of Dr. R. W. Reid, of New 
York City, with whom I saw the case in consultation. The child had a very severe 
attack of scarlet fever. It w v as of a septic character. Necrotic membranes could be 
seen over the pharynx and tonsils. There was persistent fever. The child was 
decidedly rachitic. The case was complicated with an acute nephritis. The urine 
was very scant and was loaded with albumin and casts. Later the right ear dis- 
charged pus very freely. 

When I saw the child there was a superficial swelling over the mastoid which 
pushed the ear forward. The inflammatory condition was local and due either to 



SCARLET FEVER. (J 13 

periostitis or to a local adenitis, remotely dependent on the middle ear suppuration. 
An incision made liberated a large quantity of pus. The child died of general septi- 
caemia following toxic nephritis. 

Angina Ludovici (Tippet Neck). — This may occur about the fifth day 
of the disease, though more commonly seen early in the second week' of the 
attack. 

The skin is indurated, glossy, and may pit on pressure, though it may 
give no sense of fluctuation. The process may be limited to the angle of 
the jaw or involve the entire neck; it may extend downward to the clav- 
icles and upward along the sides of the face and head, rendering the head 
almost if not wholly rigid. The diffuse cellulitis of the deeper tissues con- 
stitutes one of the gravest complications of scarlet fever, proving almost 
invariably fatal. Death results from a rupture of one of the large vessels, 
the jugular vein or internal carotid artery, or, as a result of thrombosis 
or embolism, with fatal meningitis or pyaemia. The greater the toxaemia, 
the more pronounced the lymphatic enlargement. 

The Lymph Glands. — The neighboring glands are enlarged and tender 
on palpation. The infiltration of the glands may be extreme, and in rare 
instances an excessive infiltration of the cellular tissue of the neck occurs, 
which becomes hard and indurated, and occasionally renders the head im- 
movable. 

Phlegmonous Inflammation of the Neck — Diffuse Cellulitis. 1 — Scham- 
berg studied the glands in 100 cases of scarlatina. He found the maxillary 
glands enlarged in 95 per cent, and the submaxillary glands enlarged in 36 
per cent, of his cases. The posterior cervical glands were found enlarged 
in 77 per cent, of the cases. Sometimes the parotid glands are also in- 
volved. Frequently the inflammatory condition persists and suppuration 
occurs, resulting in so-called phlegmonous inflammation. Even when freely 
incised there is danger of pus burrowing beneath the connective tissue. 
Sometimes a rapid and diffuse cellulitis with excessive infiltration of the 
deeper tissues is associated with the suppurative process. 

Retropharyngeal abscess occurs occasionally. 2 Bokai found 6 cases out 
of 664 cases of scarlet fever. 

Schamberg, in a study of the lymphatic glands in scarlatina, found the 
various groups enlarged in the following proportion in 100 cases : — 

Inguinal glands 100 per cent. 

Axillary 96 per cent. 

Maxillary 95 per cent. 

Posterior cervical 77 per cent. 



x Schamberg: Annals of Gynaecol, and Pediatry, December, 1889, vol. viii, p. 39. 
2 Jahrbuch f . Kinderheilkunde, vol, x, p. 108. 



614 THE INFECTIOUS DISEASES. 

Anterior cervical 44 per cent. 

Submaxillary 36 per cent. 

Epitrochlear 26 per cent. 

Sublingual 25 per cent. 

As a result of the analysis of these 100 cases he finds that the maxillary 
glands commonly attain the largest size, and also most frequently undergo 
suppuration. In all cases examined on the second and third day of the 
disease the enlargement of the lymphatic glands was well marked. 

Scarlatinal synovitis (so-called scarlatinal rheumatism or pseudorheu- 
matism) is occasionally met with. Ashby 1 met with this condition in 2 per 
cent, of his cases. 

Hodge found synovitis in 117 out of 3000 cases studied, or 3.2 per 
cent. There are two distinct forms: — 

(a) Simple catarrhal or serous synovitis. 

(b) Suppurative or purulent arthritis. 

The streptococcus pyogenes has been found in both forms in pure 
culture and combined with other micro-organisms. 

This complication occurs more often in children over 5, and is rarely 
met with in children under 3, according to Holt. 

The symptoms met with are : Pains in the affected joints, swelling, 
which may or may not be marked with slight impairment of motion, some 
redness, and a slight rise in temperature. 

Owing to an effusion of serum, large joints, such as the knee and 
shoulder, remain swollen many weeks. When suppuration develops in the 
involved joint, Henoch claims that it is due to emboli, following septi- 
caemia. 

The Kidneys. — There are three forms of involvement of the kidneys in 
scarlatina : — 

1. Transient febrile albuminuria and the interstitial catarrhal ne- 
phritis. 

2. Septic nephritis. 

3. Post-scarlatinal nephritis. 

Transient albuminuria occurs in three-fourths of all eases of scarlet 
fever. It does not differ from a "febrile albuminuria" seen in all acute 
infectious diseases associated with high temperatures. It has no special 
significance. 

Catarrhal nephritis not infrequently occurs in the first week in cases 
of moderate severity. The urine contains, besides albumin, degenerated 
epithelial cells, mucous cylindroids, and rarely epithelial or even hyaline 
casts, occasionally a few red and white corpuscles. 



1 British Medical Journal, 1883, vol. ii, p. 514. 



SCARLET FEVER. 



615 



Clinically, we have slight evidence of oedema. Pathological changes 
frequently take place without a trace of albumin or without the presence of 
casts. Such cases have been reported. 1 

Septic Nephritis. — Where the scarlatinal virus causes a general tox- 
aemia, and we have grave throat symptoms accompanied by necrotic de- 
posits on the tonsils and pharynx, there are always swollen glands. Ne- 
phritis develops from the intensity of the infection caused mainly by the 
streptococcus pyogenes. In many instances death occurs before well-de- 
fined symptoms of nephritis are made out. In such cases there is no 
dropsy and uraemic symptoms are absent. In rare instances the urine is 
normal during the entire attack until a post-mortem shows the existence 
of nephritis. 



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Fig. 196. — Septic Nephritis from Riverside Hospital. 



Post-scarlatinal Nephritis. — When the acute symptoms subside and 
nephritis develops it is called poet-scarlatinal nephritis. This nephritis is 
not always glomerular. Jurgensen's statement that the effect of the in- 
flammatory irritant depends not only .upon its virulence (toxicity), but 
upon the length of time during which it acts upon a given local site, is 
extremely interesting and important. 

'The symptoms may be sudden, although if daily examinations of the 
urine are made a gradual diminution in the quantity secreted in twenty- 
four hours will be noted. 

The child who has seemed apparently well and convalescing becomes 
pale, is restless and irritable, and if old enough complains of headaches, 



Corlett: 



'Treatise of Infectious Exanthemata, 



201. 



616 



THE INFECTIOUS DISEASES. 



thirst, and loss of appetite. Constipation may be present. Vomiting is 
usually an early symptom of nephritis. 

The earliest symptoms of nephritis are: rise of temperature, occur- 
rence of oedema, however slight, involving particularly the lower eyelids, 
with distinct puffiness of the eyes. Sometimes the whole face is swollen 
and bloated. The feet and legs are cedematous, so also the scrotum and 
penis in the male, and the labia majora in the female. Such oedema may 
also be seen on the dorsum of the feet and upon the knuckles. There is 
pitting on pressure. 

ROUND EPITHELIAL CELLS RED BLOOD CORPUSCLES 
PROBABLY FROM CONVOLUTED { I 



TUBULES 



EPITHELIAL AND 
I PUS CAST 



GRANULAR 
CAST 




EPITHELIAL 

CELL 
PROBABLY FROM 
VAGINA 



Fig. 197, 



HYALINE CAST 



PUS CORPUSCLES 
-Drop of Urine from a Case of Post-scarlatinal Nephritis seen in 
consultation by the Author. (Original drawing.) 



The urine is greatly diminished in quantity, so that several teaspoonfuls 
only may be passed in twenty-four hours. The reaction is acid. Specific 
gravity is from 1.006 to 1.065, the latter being rare. The amount of urea 
is under 2 per cent. Albumin is present from 0.5 to 1 per cent, and 
higher. The diazo reaction is of no value in scarlet fever. 

Microscopically. — There may be present hyaline, epithelial, granular 
and blood casts, fragmented renal epithelium, white and red blood-corpus- 
cles ; the latter in varying numbers ; uric acid and oxalic acid in crystal- 
line and amorphous form, and more or less granular debris. 

Cases are seen now and then in which almost normal conditions of the 
urine prevail and still nephritis exists. 

Nephritis usually exists a few weeks, although obstinate cases may 
continue for months and even years. 



SCARLET FEVER. 617 

Great care should he exercised in giving the prognosis in cases of post- 
scarlatinal nephritis. Uraemia, when occurring during nephritis, is a grave 
symptom. It is usually preceded by vomiting, stupor, and peculiar twitch- 
ings of the facial muscles. 

The pulse is slow ; the temperature subnormal ; the tongue is dry. 
Sometimes just the reverse exists and there is high fever, very frequent 
and small pulse; the respirations are short and hurried, and the skin dry. 

Convulsions may develop, clonic in character, of varying intensity, in- 
volving the face and extremities as a whole. Sometimes only distinct 
groups of muscles are involved. Cyanosis is marked, complete suppression 
of urine follows, coma ensues, and usually these cases end fatally. 

Anasarca is frequently associated with or subsequent to oedema. We 
frequently have serous exudations into the serous cavities — pleura, pericar- 
dium, or peritoneum. (Edema of the lungs, sometimes oedema of the larynx, 
results, and is usually fatal. Mayr mentions oedema of the pia mater and 
ventricles of the brain. 

The Diagnosis. — When fever exists accompanied by an inflamed throat 
and an eruption over the body, then the diagnosis of scarlet fever can be 
made. Later on we have desquamation. The most characteristic early 
symptoms of a typical scarlet fever are: Intense redness of the faucial 
mucous membrane, sore throat, early and persistent vomiting, fever, thirst, 
and increased pulse-rate. The tongue is very characteristic — strawberry 
appearance. (See Plate XXVIII.) Sometimes an attack of scarlatina is 
ushered in by convulsions. Older children complain of an intense headache. 
There is marked constitutional depression and aching of bones. Von Leube 
maintains that vomiting occurs more often as an initial symptom in this 
than in any other disease, excepting pneumonia. There is nothing peculiarly 
characteristic in the early temperature of scarlet fever. It remains elevated 
after a sudden rise, and subsides gradually by lysis toward the end of the 
first week. 

Drug Eruptions. — Great care must be taken to learn if a child has 
received belladonna, opium, quinine, or antipyrin. These drugs give an 
eruption similar to scarlet fever. We should always learn if such drugs 
have been given before making a positive diagnosis. 

Course. — Scarlet fever usually runs its course in about six weeks from 
the beginning of illness. The febrile stage usually subsides during the first 
week, rarely later than the tenth day. It is spread by cases in the early 
stages of the disease. Such children usually complain of headache, nausea, 
and vomiting. A superficial examination or a careless examination of these 
"spoiled stomachs" has frequently been the cause of the spread of scarlet 
fever, children being permitted to go to school. In the pre-exanthematous 
type the diagnosis is difficult unless the throat is carefully inspected. No 



618 THE INFECTIOUS DISEASES. 

child should be permitted to attend school until the last evidence of desqua- 
mation has disappeared. 

Prognosis.— It is very difficult to determine the outcome of a case, 
especially at the beginning of scarlet fever. A mild rash may have serious 
complications and a severe rash may run a very mild course without com- 
plications. 

Individual susceptibility plays an important part in forming an 
opinion as to the outcome of any case of scarlet fever. The following 
symptoms should influence an unfavorable prognosis: continued hyper- 
pyrexia; continued vomiting; delirium or other cerebral symptoms, such 
as convulsions or stupor ;• an irregular anomalous or poorly developed rash, 
if intense, suggests extreme virulence; an extremely rapid and feeble or 
irregular pulse. Great stress should always be laid on the condition of the 
heart. Other complications, such as broncho-pneumonia, or diphtheria, or 
kidney disease, should be noted as very serious complications. 

Treatment. — Isolation and Care: In New York City cases of scarlet 
fever are excluded from school for at least five weeks, or until desquamation 
is complete and all purulent discharges have ceased. If quarantine is ob- 
served by the family, children and others who have had the disease may 
return to school. If children or other members of the family who have 
not had scarlet fever are immediately removed to another address, they may 
return to school at the end of five days if in the mean time they do not 
develop the disease, but they must present a special school certificate issued 
by the department. If they continue to reside at home, they cannot return 
to school until the case of scarlet fever has been officially discharged by the 
Department of Health. 

Hundreds of physicians, students, and nurses observe cases of scarlet- 
fever without coming into direct contact with the patient, and no infection 
takes place. When, however, physicians and nurses are exposed to the 
patient's cough or come into direct contact with the salivary secretions from 
the nose or mouth, then such persons run the risk of infection. 

Hygienic Treatment — The temperature of the room should be from 
68° to 72° F. Fresh air must be admitted; hence proper ventilation is 
imperative. In winter the patient should be well protected from draughts. 
Sunshine is imperative, although the eyes should be shielded from direct 
sunlight. A tepid sponge-bath can be given every morning, and also in the 
evening, especially if there is profuse perspiration. The child's linen should 
be changed once a day. When the eruption causes itching, the body should 
be rubbed with cold cream, carbolated vaseline, or the following recipe is 
very useful : — • 

Ifc Calamine .'...' '. 1 drachm 

Ung. aq. rosae . . . . ; 1 ounce 

M. et ft. ungt. 

Sig.: Apply over the body once or twice a day. 



SCARLET FEVER. 619 

Forchheimer advises the addition of menthol, 1 per cent., to relieve 
itching. This can be added to the above. 

General Treatment. — Stimulate the Emunctories: The bowels should 
always receive attention, whether constipated or not; a dose of calomel or 
several wineglassfuls of citrate of magnesia or villacabras, in wineglassful 
doses, three times a day, will be found very serviceable. 

Lemon juice in the form of lemonade is very serviceable in stimulating 
the secretion of urine, and also for quenching thirst. The citric acid cer- 
tainly has a~beneficial effect on the throat. 

I have always seen the best results from keeping* the bowels loose and 
the kidneys active. That we eliminate toxic products in this manner no one 
can deny, and we certainly can do no harm by this preliminary treatment. 

Fever. — The use of tepid water as an antipyretic measure is the 
safest means of reducing fever without depressing the heart. Each fever 
should be studied by noting how much depression is caused by it — how the 
• child stands the temperature. If the child appears bright and cheerful 
and there is little constitutional disturbance from high fever, then cool 
sponging or tepid packs may be ample; if, however, there is marked de- 
pression, then a warm bath may serve our purpose much better. When a 
bath is used, the child should be immersed in a tub of water having a tem- 
perature of 90° F., and after the patient is immersed add cold water or ice 
until the temperature of the water is reduced to 80 F. In all a bath should 
last about three minutes, not longer than five minutes. It is important to 
watch the pulse while the child is in the bath. The temperature should be 
taken before and about ten minutes after the bath to note the fever. We 
can then see what effect has been produced. Such baths may be repeated 
in three, four, or six hours, depending on the individual requirements. 

An ice-cap may be placed on the head after the bath. 

The treatment of fever. is of the greatest importance. When there 
are stupor, drowsiness, and delirium, the tepid bath will be indicated. 
Cold packs and cold sponging are also valuable. Antipyrine, phenacetine, 
and quinine are extolled by some and condemned by others. When used 
they should always be combined with musk or camphor, or given with coffee 
to counteract the well-known cardiac depression caused by the antipyretics 
belonging to the coal-tar series. 

In the treatment of high temperature in scarlatina and infectious dis- 
eases, injections of sulpho-carbolate of soda, 10 grains to a pint of cool 
water (temperature, 70° F.), is one of the best means of reducing fever. 
These injections should be repeated every three or four hours. (Read also 
•the "Influence of Serum on the Temperature," page 627.) 

Fever can also be reduced by the use of the following mixture :— 



620 THE INFECTIOUS DISEASES. 

B Tinct. aeoniti 20 drops 

Spir. mindereri '. 2 ounces 

Syr. limonis 1 ounce 

M. Sig.: Teaspoonful every hour until sweating is produced, for a child 5 
to 12 years old. Younger children one-half the dose. 

Weak Pulse. — When the first sound of the heart becomes weak, or the 
two sounds lose their normal tone, stimulation must be commenced. The 
same is true if the pulse is weak; 1 / 100 grain of strychnine can be given 
every three hours, or oftener, if necessary. It must be borne in mind that 
children tolerate strychnine, in toxaemic conditions in very large doses. It 
is a good plan to give coffee with the strychnine or to combine it with caf- 
feine or musk. Digitalis is indicated if the pulse is weak and of low ten- 
sion. It should not be used continuously, as it irritates the stomach, and 
in its stead tincture of strophanthus should be used. Champagne or whisky 
is tolerated in extremely large doses. Henoch considers camphor one of the 
best stimulants when given hypodermically every two or three hours : — 

IJ Camphor » 1 gram 

Ether 10 grams 

Sig.: Use hypodermically. 

Coma. — In coma the subcutaneous use of sodium-caffeine-benzoate 
. stimulates the heart and arouses the child from stupor. It also stimulates 
diuresis. When bloody urine exists in addition to gallic acid, suprarenal 
extract or its alkaloid, adrenalin, can be used in very small doses. 

Spartein sulphate, % to % grain, injected hypodermically, with dis- 
tilled water, is useful in cardiac weakness. When meningeal symptoms, such 
as delirium, cannot be relieved by hot baths and bromides internally, then 
the application of several leeches behind the ears, over the mastoid, will be 
very useful. 

Nephritis. — When the first symptom of nephritis appears we must aid 
the kidneys, skin, and bowels by eliminative treatment. In this manner 
only can the blood-pressure be reduced. The child must be kept in bed, 
well blanketed. The diet should consist of milk, milk and seltzer, milk and. 
cereals, and buttermilk. If the stomach is irritable, then the milk should 
be peptonized. When extreme repugnance to milk exists, then chocolate 
may be substituted or some vanilla flavor added to the milk. For thirst 
give whey, lemonade, or orangeade. To stimulate diaphoresis, hot baths 
aided by hot packs will be serviceable. The temperature of the bath should 
be 100° to 110° F. The child is immersed from five to ten minutes. The 
surface of the body must be continually rubbed during the bath. The pa- 
tient when taken out of the bath is placed between hot blankets for one 
hour, so as to aid diaphoresis. To give the hot pack the child should be 
wrapped in a blanket wrung out of hot water, temperature 100° F., and 



SCARLET FEVER. 



621 



then covered with a dry blanket, over which is placed a rubber cloth. The 
blanket can also be covered with oil-silk. 

The pulse should be watched during the bath, and the child should 
at once be removed if signs of weakness appear. 

The Hot-air Bath. — Place the child in bed and cover with two blankets. 
On either side place hot-water bottles or hot bags of sand so protected that 
the child cannot be burned. Over these place a rubber cloth or a raincoat. 
Over the rubber place another blanket. Sweating occurs very easily and 




Fig. 198. — Coffey's Glass Apparatus Devised for Hypodermic Saline 
Injections. The temperature of solutions can be seen and regulated by the 
thermometer. A second thermometer shows the temperature of the solution 
as it enters the body. This apparatus can also be used for colonic flush- 
ings by removing the needle and attaching a rectal tube. 

very quickly in this manner. In an emergency the ordinary flat-iron can be 
used, instead of the hot-water bottles, for a hot-air bath. 

Pilocarpin and jaborandi are such cardiac depressants that they are 
merely mentioned to be condemned. Nitroglycerine is very valuable. When 
a general dropsy appears, the danger of effusion into the serous cavities 
must be borne in mind. When necessary the effusion should be relieved by 
aspiration. The quantity of urine passed is the most important point which 
should guide us in determining the result of the treatment. 



622 TH E INFECTIOUS DISEASES. 

Liquids should not be forced under the impression that' we are stim- 
ulating diuresis. Experience has taught the Staff of the Willard Parker 
Hospital that we can stimulate the kidneys by careful dieting/ and by 
restricting liquids. The following case occurred during my service^ and 
will illustrate the treatment. 

Mary S., 5 years old, was ill three days before admission to the Riverside Hos- 
pital. Diagnosis: Scarlet fever. Her diet consisted of milk 96 ounces in twenty- 
four hours. She later received also soup and cereals. An injection of 10,000 anti- 
toxin units was given. Three days later the child' complained of painful joints. The 
diet was restricted to milk. 

The urine showed a* specific gravity of 1018, contained free blood and abundant 
granular casts. Diagnosis: Acute renal congestion. Medication consisted of agurin 
5 grains every four hours, nitroglycerin Vioo-grain one-half hour before hot bath. 
Liquids were forced. The pulse became weak. Strychnine y 80 -grain, whisky 1 dram, 
was ordered. The following day many course granular casts and much free blood 
were found in the urine. Whisky was discontinued. 

The diet until this time consisted of 96 ounces milk in twenty-four hours. 
Nephritis and oedema present. About 32 ounces of urine was voided in twenty-four 
hours. The following day liquids were restricted to. 22 ounces; in addition cereals, 
bread, prunes, and peaches were given. The total urine passed within the twenty- 
four hours was 35 ounces. Following day same diet was given; total urine passed 
was 40 ounces. Thus by restricting liquids we aided diuresis. 

If the quantity of urine increases and the percentage of albumin de- 
creases, then our patient is improving. The disappearance of blood cor- 
puscles and casts denotes improvement. One of the best drugs to aid 
diuresis is diuretine, to be given in doses of 3 grains for a child two years 
old, and gradually increased until 5 grains per dose is administered. This 
drug should be given at least three times a day to stimulate the kidneys. 
Another drug highly recommended by Baginsky is acet-theocine. It can 
be given in the same dosage as diuretine and the dose repeated several times 
-a day. In a certain class of cases agurin acts well, and can be recom- 
mended, because it does not disturb the stomach. Now and then I have 
noticed that marked vomiting followed the administration of almost any 
drug during the course of nephritis; hence, great care should be taken not 
on that account to condemn a drug during the course of nephritis with 
toxic or uraemic symptoms. 

Vulvo-vaginitis Following Scarlet Fever. — At the Eiverside Hospital 
during the summer of 1903, out of 100 cases of scarlet fever there were 15 
cases suffering with vulvo-vaginitis. In these there was a well-marked 
purulent discharge upon the deeper-parts of the vulva and at" the vaginal 
opening, with some redness and irritation. With this there was a distinct 
rise of temperature and some constitutional disturbance. The cases all 
yielded promptly to treatment, proving especially amenable to, simple 
astringent solutions rather than to more active germicides. 1 



Reported to me by Dr. G. L. Nicholas, Resident Physician. 



SCARLET FEVER. 623 

It is not uncommon to find cases of vulvitis and also vaginitis occurring 
in the scarlet-fever wards for which there is no adequate explanation. 

Vulvo-vaginitis as seen at the Eiverside Hospital occurs as a distinct 
complication to scarlet fever. When it occurs it shows a distinct rise of 
temperature and also a peculiar constitutional disturbance. When this 
is contrasted with the symptoms of a catarrhal otitis the similarity of both 
conditions must be apparent. Not only do we have similar bacteriological 
findings, but the infection manifests itself in a rise of temperature and 
general systemic disturbance. 

While an occasional case of true gonorrheal disease may arise in 
which the Neisser gonococcus will be found, from a large clinical experience 
in both hospital and private practice, I must say that such cases are very 
exceptional. 

Prognosis. — The prognosis is usually good, although we must bear in 
mind that if these cases are neglected serious results may follow. Infection 
may spread from the urethra into the bladder and from the bladder into 
the ureters, and infect the kidneys. 

Hygienic Treatment. — In this disease more than in any other the 
strictest attention to hygienic rules is demanded. If it is an infant that 
is so afflicted, the pads should thoroughly cover the vulva and be saturated 
with a weak solution of bichloride. This pad should be adjusted with the 
aid of a T-binder. If there is severe itching from excoriation and the child 
has a tendency to scratch, the hands should be guarded so that the infection 
cannot be carried from the genital tract to the eyes. 

Local Treatment. — Labarraque's solution is a very valuable remedy. 
It may be used in a 5 per cent, solution. My plan has been to add about 
1 ounce of chlorine, water to 1 pint of lukewarm water and irrigate morn- 
ing and evening, noting the effect. If the discharge is not lessened thereby, 
the injection should be given three times a day. 

Astringent solutions, such as sulpho-carbolate of zinc, sulphate of zinc, 
or sulphate of copper, using 1 grain to the ounce, are useful. When there 
is intense itching it is a wise plan to instill a 2 per cent, ichthyol-glycerin 
solution into the vagina after the same has been thoroughly washed with 
one of the above astringent solutions. . . 

Argyrol, 25 per cent, solution, has been used as an injection several 
times a day with remarkable success at the Willard Parker Hospital by 
the resident staff. 

The vaccine treatment consists in injections of gonococcus vaccine. 
These injections are given subcutaneously in doses of 50 million and re- 
peated daily until 1000 million dead bacteria have been injected. There 
is no specific action following these injections. My experience in some 
cases has been good, in others disappointing. The discharge was diminished ; 
in some cases it disappeared. The gonococcus, however, persisted. 



624 THE INFECTIOUS DISEASES. 

Endocarditis or Pericarditis. — The heart requires careful watching, 
especially if symptoms of rheumatism appear. Sudden death will frequently 
occur from heart-failure. 

A case of this kind was seen by me in consultation with Dr. S. Straus, of New 
York City, in which a child desquamating with scarlet fever had myo- and endo- 
carditis. There was a general anasarca. The pulse became very weak during the 
hot-air bath. The child died suddenly. It is very apparent, therefore, that the 
hot-air bath is not without its dangers. 

Otitis. 1 — The escape of pus from the external auditory canal is by no 
means rare. The extension of a bacterial infection — streptococcus inflam- 
mation — from the pharynx through the Eustachian tube can sometimes be 
aborted by local treatment. Too great stress cannot be laid on the active 
antiseptic treatment of the nasopharynx as a means of prophylaxis. When 
earache occurs, no matter how slight, then the ears should be examined. 
It is better to call an aurist to make sure of the diagnosis and treatment, 
rather than risk the dangers of mastoid inflammation, with the possible 
extension of a meningitis and a fatal outcome. Until then, local treatment, 
such as the application of a hot-water bag to the ear, or cotton inserted into 
the ear, will afford temporary relief. The danger of using cocaine should 
not be forgotten, although it is a valuable remedy. When pus is evident, 
as shown by the bulging of the membrane, then a paracentesis should be 
performed, and the cavity irrigated with boric acid solution, or 1 part of 
hydrogen peroxide and 5 parts of sterile water. The ear should not be 
packed with gauze, but should be permitted to discharge and drain freely. 
Eestorative treatment, such as has been previously mentioned in conjunc- 
tion with nephritis in this chapter, is indicated. 

Salt-free Diet. 2 — When the kidneys are affected, their activity is 
diminished, and an excess of salt is stored in the tissues. As each molecule 
of salt requires a certain quantity of water to hold it in solution, such water 
will be abstracted from the tissues, giving rise to the dropsical condition. 
By giving a diet which is free from salt, we can decrease the oedema. 

Generally speaking, during the febrile stage and until the end of the 
second week, an exclusive liquid diet of milk or milk and barley water 
should be given. If milk is not well digested, then whey should be tried 
(see "Dietary"). Later, beef soup, mutton or chicken broth, buttermilk, 
all gruels, fruits, fruit jellies, toast, weak tea, weak coffee, cocoa, and 
chocolate. For thirst — Appollinaris, Vichy, and lemonade. The tendency 
to nephritis seems to be lessened by giving our patients a milk diet; hence 
this fact must be borne in mind. Steak juice and egg albumin, diluted 
with water, can be given later on. 



x Read also chapter on "Acute Otitis Media." 
a L'Echo Medical du Nord, January 20, 1907, p. 25. 



SCARLET FEVER. 



625 



Restorative treatment, such as iron, strychnine, malt extract, and cod- 
liver-oil, should be given after the symptoms of nephritis subside. The 
child should be kept well protected for at least two months after the first 
symptoms appear. 

As soon as the temperature falls to the normal point we can give : — 

IJ Mist, ferri et ammonii acetatis, 

Glycerini aa 1 fluid ounce 

Aquae q. s. ad 4 fluid ounces 

M. Sig.: A teaspoonful or more every three hours, in water. 



DATES OF OBSERVATIONS 




4 


5 


6 


7 


8 


9 


10 


Cent. 


Fakr. 


AM>M 


am:pm 


AM 


PM 


AfOM 


AMiPM 


am!pm 


AMiPM 


41°~ 


•6 

: i06°'z 


; 
















•8 
•6 

105° : $ 


















40°~ 


•8 
•6 

104 -2 


j. 
















39°~ 


•8 
- «6 

: 103° : 2 


71 


7a 




A 




i 






•8 

- o' i 

-102 •* 


/ 


J V 


v 


f] 


l ; A 


* * 






38°~ 


V 




\ / \ 


•8 
•6 

: ioi° : * 


'; 


\l']\ 






v- 


/ 


/ 


v 


•8 

•6 

o« 4 

-100-2 




L0 c. c. 
treptococcus 
ti Injected 










X 


37 ~ 


•8 
•6 

: 99°-2 














• 8 
•6 














Normal 

36 °~ 




Br 

0) - 


"98 '2 














•8 
•0 

: 97° : 2 














- -8 

•e 

- o-4 

-96 '2 




















Pulse 
per minute 




9? 


3 n 
<! »>>. 


35 


l§ 


35 


l? 


Respiraticma 
per minute 




cvJN 




°3« 









Fig. 199. — Temperature Chart from a Case of Scarlet Fever Treated with 
Antistreptococcus Serum. (Original.) 

Or Basham's mixture may be given : — 

T$ Tinct. ferri chloridi, 

Acidi acetici dil aa 1 fluid drachm 

Liq. ammonii acetatis 6 fluid drachms 

Aquae q. s. ad 6 fluid ounces 

M. Sig. : Tablespoonful three times daily for a child six years old. 

40 



626 



THE INFECTIOUS DISEASES. 



Serum Treatment. — Antistreptococcus serum has been extensively used. 
It has its opponents and some who extol its virtues. Baginsky 1 reports a 
series of 48 cases treated with serum, of which 7 were fatal, a mortality of 
14.6 per cent. 

A clinical study of the value of antistreptococcus serum was reported by 
me 2 in a paper read before the Section on Pediatrics of the New York 
Academy of Medicine. 




Fig. 200. — Method of Nasal Syringing employed in the Scarlet Fever 
Ward of the Riverside Hospital. (Original.) 



Antistreptococcus serum (AronsonV) was sent to me in the winter 
of 1902-1903. The serum proved very successful in a series of cases in my 
private practice. 4 

Through the courtesy of Professor Escherich I saw a number of cases 
that were treated by Moser's antistreptococcus serum at the Children's Hos- 
pital in Vienna while in Europe in May, 1903. 

All of these serum cases did remarkably well. I was impressed by the 



Berlin, klin. Woch., 1896, No. 33, p. 340. 
2 "Value of Antistreptococcus Serum," May 12, 1898. 

8 1 am indebted to Messrs. Sohering & Glatz for sending me sufficient serum 
for clinical trial. 

*New York Medical Record, March 7, 1903. 



SCARLET FEVER. 627 

excellent results, especially by the distinct fever crisis, after the necessary 
dose of serum was injected. 

The preceding chart is the record of a case occurring in my private 
practice. 

The specific action of antitoxin in diphtheria is far greater compara- 
tively than the action attained from the use of antistreptococcus serum. 

The Temperature. — The effect of the serum on the temperature shows 
that it did inhibit bacterial products. Within twelve to twenty-four hours 
after the serum injection I have seen a distinct crisis in the temperature. 
In other cases the temperature was gradually reduced by lysis. (Fig. 199.) 

Another interesting observation in most cases is the disappearance, 
almost melting away, of the necrotic membranes after the fourth day. The 
glands of the neck were swollen and subsided with the disappearance of the 
throat manifestations. The vital point consisted in a strengthening diet in 
addition to strict hygiene. I feel warranted in advocating the use of this 
serum in the treatment of -scarlet fever. 

Medicinal Treatment. — The Throat: When children are old enough 
to use a gargle they should be given a mild antiseptic solution, such as table- 
salt solution, using a pinch of salt to a wineglassful of lukewarm water. 
Gargle every hour. 

A spray consisting of normal saline solution directed against the 
pharynx and tonsils every hour is useful. If spraying is difficult, then the 
throat may be swabbed with cotton dipped in saline solution. High tempera- 
ture will frequently subside if the nasopharynx is properly irrigated. 

The septic accumulations are very serious and cause profound toxaemia 
unless cleansed thoroughly. 

Tincture of iodine or LugoPs solution carefully applied to the tonsils 
and pharynx, once only, is advised. Local applications of 50 per cent, 
resorcin solution in alcohol, applied on cotton several times a day, are also 
advised. 

Nasal Douching. — My preference has always been for mild saline 
douches. Hold the child firmly and cleanse the nares with a nasal tip 
attached to a fountain syringe, at a height of no more than two feet. Per- 
manganate of potash, several crystals to a pint of water, is very good when 
there is fcetor. 

Ifc Natrium sozoiodol, 

Flor. sulphur of each, equal parts. 

M. For insufflation into the nostril three or four times a day. 

This seemed to exert a very beneficial effect on the necrotic tissue, 
causing a clearing of the throat. 

If the treatment causes nausea or vomiting, then the sozoiodol natrium 
can be given internally in the following manner : — 



628 THE INFECTIOUS DISEASES. 

Ifc Natrium sozoiodol 2.0 

Aquae 100.0 

M. Sig.: Teaspoonful every hour. 

Swollen Lymph Glands. — In septic scarlet fever with necrotic pseudo- 
membranes in the throat, the adjacent lymph glands will be swollen. 

At times there is an extensive oedema and infiltration extending into 
the glottis, which can result in asphyxia. 

Such cases will be benefited by the use of thorough inunctions of 
Creole ointment} It must be distinctly understood that no result will be 
noted unless the ointment' is rubbed into the swollen glands at the angle 
of the jaw for at least fifteen minutes. This can be repeated several times 
a day. 

I also have used inunctions along the spine to promote absorption over 
a greater area. This has proven very efficacious in many cases. 

Forchheimer advocates the use of sterile normal salt solution subcu- 
taneously. This is done to stimulate diuresis and also to aid in the elimi- 
nation of toxins. In my own practice I have found marked benefit from 
irrigating the colon with a rectal tube introduced about six inches, using 
several pints of normal salt solution at a temperature of 100° to 105° F. 
This is a very rapid and convenient method in an emergency, especially 
when one is hampered by necessary irrigators and needles, as we require 
only an ordinary fountain syringe and the rectal catheter connected with it. 

Immunity from Diphtheria. — An injection of 500 to 2000 antitoxin 
units will confer immunity from diphtheria in a case of scarlet fever. 

Diphtheria. — If diphtheria complicates scarlet fever, then the usual 
treatment of diphtheria should be instituted (see chapter on "Diphtheria"). 

At the Eiverside Hospital every case of scarlet fever is injected with 
500 to 1000 diphtheria antitoxin units as a prophylactic measure. By this 
means Dr. Eichardson believes that we have reduced the complication of 
diphtheria in about 50 to 75 per cent, of all cases. 

Septic Scarlet Fever. — In septic cases where the system is overwhelmed 
with toxin, we frequently have extreme prostration, rapid pulse rate, and 
temperature ranging between 100° and 101°. In other cases the tempera- 
ture may rise to 104° or 105°, all depending on the disturbance of the 
thermic center. It is in this class of cases that we welcome almost any 
remedy. 

Convalescent Human Blood-serum. — The intramuscular injections of 
convalescent blood-serum, as a therapeutic agent, have been extensively 
used both in this country and abroad. It is especially indicated where 
septic conditions exist. I have seen cases of septic scarlet fever at the 
Willard Parker Hospital injected with 200 to 300 c.c. of serum from cases 



1 Schering & Glatz, agents, New York City. 



SCARLET FEVER. 629 

in the fourth and fifth weeks of convalescence. 1 Within twenty-four hours 
after the injection a rapid fall in temperature is noted. Sometimes the 
temperature falls by lysis. This therapeutic measure is sufficiently impor- 
tant to encourage its use whenever possible. Intravenous injections of 0.2 
to 0.3 gramme neosalvarsan rendered very good results. Out of 12 hopeless 
cases injected, 7 recovered. 

Since the introduction of neosalvarsan, the technique of preparation 
has been greatly simplified. The neosalvarsan is dissolved in sterile water, 
and is ready for injection. For a young infant under 1 year 0.1 gramme of 
neosalvarsan is dissolved in 20 cubic centimeters of sterile water and injected 
into the jugular vein. An older child, 2 to 4 years, may receive 0.2 gramme 
of neosalvarsan in 40 cubic centimeters of sterile water. Owing to the small 
size of the median basilic vein at the bend of the elbow, it may be necessary 
to incise the skin and expose the vein to insert the needle. My preference 
has been to inject into the jugular vein. The technique is simple if the neck 
is properly supported. No systemic effect is noticeable after these injections. 
By using the neosalvarsan we avoid the complicated preparation which was 
necessary in the- use of salvarsan. 

An illustration of the technique of injecting into the median basilic 
vein may be seen on page 536. 

A series of cases of severe scarlet fever 2 in which profound toxaemia 
existed were injected with neosalvarsan. In a case of severe noma compli- 
cating scarlet fever an injection of 0.2 gramme of neosalvarsan was given 
with excellent results. 

There is no specific drug or serum in use today, so that too much 
should not be expected from neosalvarsan. 

Transfusion. 

This therapeutic measure is indicated in a series of devitalized cases 
wherein the blood-supply is weakened. Septic cases, no matter what the 
cause, are adapted to this form of therapy. Infants suffering with maras- 
mus and inanition respond to this form of treatment. In cardiac weak- 
ness following or during the course of an influenzal penumonia I have had 
exceedingly good results from its use. Likewise, this procedure has served 
me in infants weakened by prolonged diphtheria, the toxic type, as well as 
in toxic forms of scarlet fever. 

This method consists briefly in withdrawing from the donor, with the 
aid of a blunt-pointed steel needle and a record syringe, as many ounces of 
blood as desired for the transfusion. To prevent coagulation of the blood 

1 These cases were injected during my service by the Staff of the Research 
Laboratory. 

2 Reported at the International Medical Congress,, London, 1913. Section on 
Diseases of Children. 



630 THE INFECTIOUS DISEASES. 

a citrate of soda solution is added to it, and the whole kept at blood heat, 
in a sterile beaker until needed, or with the aid of Unger's apparatus direct 
transfusion can be done. Hust, in 1914, used a human blood transfusion 
by adding citrate of soda and glucose to the blood. Citrated blood was 
also recommended by Weil in 1914, who used 1 per cent, sodium citrate 
solution. R. Lewisohn found that 0.2 per cent, solution of sodium citrate 
will keep the blood fluid. His experiments with human blood transfusion 
were performed at the Mt. Sinai Hospital in New York. 

The important fact gleaned from these experiments is that the addi- 
tion of the citrate of soda prevents clotting. 

The technique of the injection has been described by Dr. A. Zingher 
in the Medical Eecord, March 13, 1915. A suitable donor must be chosen. 
We have encountered no dfficulty in procuring one of the parents or uncles 
to give eight to twelve ounces of blood. The donor must be free from 
syphilis or tuberculosis. If time permits, and the case is not a desperate 
one, we should determine if the serum of the donor agglutinates or hemo- 
lyzes the patient's red blood-cells or vice versa. This method is described 
by Ottenberg and Epstein. In emergency cases as met with by me it was 
impossible to take the time to study the agglutination and hemolysis of the 
donor's blood. Ottenberg states that while it is better to test each donor's 
blood, he believes that danger exists in but 2 per cent, of all cases, or one 
in fifty. 

The technique of transfusion is so simple that it can be successfully 
carried out in most cases by the general practitioner in the patient's home 
without any elaborate paraphernalia. [But all must be done with sterile 
and aseptic technique. 

The donor is placed in a recumbent position. A piece of rubber tubing 
and an artery clamp acts as a tourniquet above the elbow. To a 30 c.c. 
record syringe a steel needle one and one-half inches long is attached and 
inserted into the tense median cephalic vein. A syringeful of blood is 
aspirated. The needle is left in situ. The barrel of the syringe detached, 
and the blood quickly emptied into a large beaker containing two and one- 
half| c.c. of a 10 per cent, solution of sodium citrate. To keep the needle 
free, with the aid of a small record syringe, inject a few drops of a 1 per 
cent, sodium citrate solution. Too rapid depletion is not safe, and may 
result in a sudden cerebral anemia. It is much safer to allow the circula- 
tion of the donor to be re-established before withdrawing the second syringe- 
ful of blood. 

After each addition of blood to the citrate solution the beaker must be 
thoroughly shaken, in order that the citrate may become thoroughly mixed 
with the blood. 

Choice of Vein in an Infant. — There are four places adapted for this 
method: (1) the median cephalic, (2) the median bacillic, (3) the jugular, 
and (4) the longitudinal sinus. 

The longitudinal sinus has been suggested by Tobler and Helmholz. 



SCARLET FEVER. 631 

Marfan as early as 1898 advised the use of this route for the intravenous 
administration of salt solution. Owing to the ease with which one can 
enter the sinus through the anterior fontanelle it seems as though Mature 
had left this opening as an emergency for this course of treatment in infants. 

In many of my cases the median cephalic vein was used. This being 
a very small vein in infants, it was necessary to make a small incision and 
expose the vein in order to inject the blood. The patient receives the blood 
directly into the vein. 

Baby W., born Jan. 4, 1915, was asphyxiated at birth and resuscitated with the 
aid of a pulmotor. It was a forceps case. Suffered cerebral haemorrhage. Prognosis 
hopeless. Received breast-feeding, but was so weak that its first cry was noted when 
1 month old. Always regurgitated or vomited its food. The infant when I first saw 
it was 7 weeks old, and weighed 7^ pounds. It had an irregular, thready, and in- 
termittent pulse, was fed with difficulty, was listless and cyanotic. The stools con- 
tained undigested particles of cheese and mucus. The circulation was bad, extremi- 
ties cold, the heart sounds were feeble. Eight ounces of citrated blood were transfused. 
An uncle of the infant was the donor. The blood was injected in the median cephalic 
vein. There was slight improvement in the color of the skin during the transfusion. 
On the following day the infant was brighter, had more color in the cheeks and ears, 
began to notice objects, and appeared more natural. Gained 6 ounces during the 
first week after the transfusion. The second week gained 6 ounces more. The child 
is now over 2 years old, and normal in every respect. 

Eegarding the effect of normal blood during an acute infectious dis- 
ease much has yet to be learned. In some instances the blood of con- 
valescents from scarlet fever 1 was utilized for both intravenous and intra- 
muscular injections in the severer forms of scarlet fever, and it seems that 
there is more specific bactericidal power in the blood of a convalescent than 
there is in the normal human blood. This leads Ottenberg to state that 
the blood of persons who have recovered from an infectious disease or who 
have been artificially immunized has specific properties not only in the 
antibodies of the plasma, but possibly also in the cells. 

Observation and Treatment of the Donor. — The pulse of the donor 
requires careful supervision, whether we draw blood with a sjTinge or 
otherwise ; less supervision, however, with the syringe method. Most of the 
men whom I have seen did best when they were blindfolded, as the sight of 
blood invariably caused nausea, and sometimes syncope. The pulse is 
invariably slowed, and should be watched for signs of collapse. We in- 
variably stimulate the circulation after withdrawing eight ounces or a pint 
of blood by giving the donor one-half pint of milk with the yolk of egg 
added, or warm broth, or coffee, to which the yolk of egg is added. No 
other stimulation was necessary. It is important to have the donor rest at 
least an hour after withdrawing the blood. 

Influence of Fever. — A decided drop in the temperature followed in 
each of six transfusions (transfused cases). In one instance the tempera- 
ture dropped from 104° to 100° within six hours. In another instance the 

x Park and Zingher, Treatment of Scarlet Fever with Fresh Blood from Con- 
valescent Patients: New York State Journal of Medicine, March, 1915. 



632 THE INFECTIOUS DISEASES. 

temperature dropped three degrees within six hours by lysis. This decided 
antithermic effect could be accounted for in no other way excepting directly 
due to the influence of the fresh blood-supply. Ottenberg and Libman have 
made a similar observation on the influence of transfusion on fever. "Of 
particular interest is the transfusion on the fever which is such a conspicu- 
ous feature of a large number of cases of pernicious anemia. It has been 
found in over 60 per cent, of the cases (in one report as high as 80). In 
5 of the 6 febrile cases we investigated the fever disappeared after trans- 
fusion. This phenomena is not peculiar to this form of anemia, for among 
16 other cases of anemia due to a variety of causes (including infections) 
febrile before transfusion, 8 became afebrile after it. These observations 
lend strong support to the view that there exists a fever dependent upon 
anemia as such, the so-called anemic fever. Transfusion is the best remedy 
for pernicious anemia; it never cures, but it leads to remissions in about 
half the cases." 

The Advantages of Syringe Transfusion. — There are decided advan- 
tages in the direct or syringe method as advised by Lindeman, Zingher, and 
others. There is no traumatism, no pain, and a decided absence of shock. 
The most important point, however, is that the exact amount transfused 
is known. Another advantage of the syringe method is that the donor's blood 
can be removed, mixed with an anticoagulant such as citrate of soda, and 
then taken to the patient. This may be an important factor in securing 
blood from a donor who is sensitive about going to a hospital or who does not 
care to come in immediate contact with the recipient. This latter may be 
an important point if the patient (recipient) has an acute infectious dis- 
ease which could be! transmitted to the donor. 

From the communication here presented I feel justified in making the 
following deductions : — 

1. That this is a very useful method of therapeutics. 

2. That it can be used in the private house as well as the hospital. 

3. That very little assistance is required. 

4. That many marasmic and underfed infants, and especially cases of 
secondary anemia, are adapted to this treatment. 

One striking point was forcibly brought out in the marasmic case 
under consideration. The infant's temperature was subnormal, the extremi- 
ties cold. A general cyanosis was evident in the lips as well as fingernails 
and toenails. . The circulation was stagnant. Within a few hours after 
the transfusion the cyanosis was lessened, the body temperature rose one 
degree, and this improvement continued and aided the general nutrition. 
I am, therefore, encouraged, to believe that transfusion should be added to 
our therapeutic measures in marasmic infants. 

It is a great pleasure to acknowledge the valuable association of Dr. 
A. Zingher and Dr. Abrahams, of the Eesearch Laboratory, and the co-op- 
eration of the Eesident Staff of Willard Parker Hospital, in furnishing 
clinical assistance and bedside notes. 



CHAPTER X. 

VARICELLA ( CHICKEN-POX ) . 

Varicella is a specific infectious disease of an acute character. The 
eruption consists of vesicles, which appear in successive crops. The attack 
lasts in all from four to fourteen days. After one attack the child is usually 
immune during the rest of its life. 




Fig. 201. — Pustules surrounded by an inflammatory areola. From the 
service of the Willard Parker Hospital. (Courtesy of Dr. Howard 
Fox.) 

Etiology. — This disease is seen only in young children; the older the 
child, the less liable it is to have chicken-pox. Nurslings are frequently 
afflicted. 

Hutchinson states that in his experience adults are almost absolutely 
immune from this disease. In my own practice the majority of cases seen 
by me have been in children between the second and tenth years of age. 

Pathology. — The pathological lesions are confined wholly to the epi- 
dermis. "The vesicles contain granular fibrin, a moderate cellular exudate, 
cellular debris, and serum ; this differs markedly from the exudate in variola, 
which is usually very rich in cells, especially plasma cells. The pock in 
varicella is shallow, rarely involving the papilla? of the cutis, and as its con- 

(633) 



634 THE INFECTIOUS DISEASES. 

tents are absorbed, the superficial covering is cast off in the form of a 
brownish scab, sometimes with marked pigmentation, but no resulting scar. 
The occurrence of a scar following the varicella lesion is occasionally seen." 
Diagnosis. — The distinguishing features of varicella are: "(a) Its 
mild prodromal symptoms, which may be wholly absent, (b) The appear- 
ance of the eruption on the trunk, where it is usually more abundant than 
on the face and hands, (c) The multiform character of the eruption, its 
superficial position, comparable to drops of water sprinkled over the skin, 
and its appearance on the same region in successive crops, (d) Its mild 
constitutional symptoms and short duration ;. the disease usually terminates 
within from five to fourteen days, (e) Varicella is mildly infectious and 
always gives rise to a like disease." 

A nursing infant, about five months old, refused the breast, and seemed to 
show a general malaise. The infant had previously enjoyed good health. The 
nursing was regularly carried out and the bowels were normal. The temperature 
was 100° F. There was no cough. On the second day of this malaise several 
vesicles appeared on the abdomen and back. Later, some vesicles appeared on the 
buttocks, thighs, and in the roof of the mouth. There was no constitutional dis- 
turbance and on the third day of illness the infant again nursed as usual. Several 
successive crops appeared, . and each eruption remained about three days. Local 
treatment consisted in dusting the parts with cornstarch. Bathing was prohibited 
and small doses of calomel were given. No complications followed. 

Differential Diagnosis. — This disease may be confounded with variola, 
as some mild cases of variola resemble chicken-pox. "The superficial strata 
of the epidermis are principally involved, and a serous exudate, which is 
frequently the first symptom of the disease, occurs at this point, resulting 
in a transparent, thin-walled vesicle, while in variola the shot-like, deep- 
seated induration and subsequent vesicular formation are sufficiently dis- 
tinctive to warrant a differential diagnosis. The lesions in varicella, as a 
consequence, are easily destroyed, and when seen present a transparent, 
beady appearance, some of which, having ruptured, leave excoriated areas; 
whereas in variola it is impossible to rupture the lesions so as to evacuate 
the entire contents without numerous punctures or by totally destroying the 
diseased area." 

In variola we have more uniformity of development : first papules fol- 
lowed by pustules and ending in desiccation, leaving black crusts. In 
chicken-pox we find a varying of lesions at the same time, so that we may 
have macules, vesicles, and pustules at one and the same time. In variola 
the eruption is thickly seen on the face and hands, the exposed portions of 
the body. In chicken-pox the eruption is seen on the abdomen and back; 
the parts protected by clothing are usually first covered. When called to 
doubtful cases the following points are worth noting: — 

Umbilication is seen in smallpox; it is absent in chicken-pox. "The 
length of time since vaccination, and whether or not the patient has ever 



VARICELLA. 



635 



had chicken-pox. Smallpox is extremely seldom encountered within three 
or four years after vaccination, while after that time the number of cases 
of varioloid or abortive smallpox steadily increase. Chicken-pox, like 
smallpox, occurs but once in the same individual. Prodromal symptoms 
are always present for several days, usually three, in variola; absent or of 
a few hours' duration in varicella. 

"The temperature often renders valuable aid in differentiating between 
the two diseases.' In variola it rises rapidly, and even in mild or abortive 
cases usually reaches 103° to 104° F., when, on the appearance of the rash, 
a crisis takes place and it falls to the normal within a few hours, where it 
may remain throughout the remainder of the disease. Varicella, on the 




Fig. 202. — Temperature Curve in Varicella. (Original.) 



contrary, is seldom ushered in with fever, but the temperature usually rises 
one or more degrees as the eruption develops. When the case is seen for 
the first time after the eruption has appeared and, as often occurs, no definite 
history can be obtained, other symptoms must be relied upon." 

Varicella may also resemble impetigo. Impetigo is first seen on the 
face, especially about the mouth and nose. It is also seen on the hands. 
In studying the regional appearance of the eruption one can readily see 
the transmission and inoculation from face to hands and vice versa. This 
condition is never met with in chicken-pox. Impetigo may last weeks and 
months. Chicken-pox rarely exists more than two weeks. Impetigo is 
contagious and not infectious. Chicken-pox has been successfully inocu- 
lated. 

Prognosis. — The prognosis is invariably good. I have never heard of 
a fatal case of chicken-pox. Complications should, however, be guarded 
against and not invited by carelessness. 



636 



THE INFECTIOUS DISEASES. 



Treatment. — A child suffering with chicken-pox should be put to bed 
and strictly isolated. Healthy children should not come into contact with 
a case of chicken-pox for at least two weeks. 

The diet should be liquid, and feeding should be given at regular 
intervals. The bowels should be loose, and if necessary stimulated by the 
aid of a laxative. 

For the eruption flannels and woolens should be avoided, and a cool, 
loosely fitting linen or muslin shirt or gown should be worn. It is safe to 



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Fig. 203. — Erysipelas Following Varicella. Locally, pure alcohol in 
which 1 : 2000 bichloride mercury was dissolved was applied on the erysipela- 
tous surface continually. Case recovered. (Original.) 

prohibit the daily bath until the eruption has disappeared. I prefer to 
dust the skin with some bland dusting powder, such as talcum, cornstarch, 
or rice powder, several times a day. Iron and tonics may be given later if 
required. Locally, a paste made by mixing bicarbonate of soda with cold 
water and applied to the chicken-pox is cooling. 



Baby B., five months old, was attended by me in January, 1905. The infant 
had a severe form of varicella with gastric disturbances, such as vomiting and 
diarrhea. On the sixth day after the appearance of the chicken-pox the infant 
scratched its arm. On the following day there was a temperature of 102° and a 



VARICELLA. 637 

diffuse swelling surrounded the upper arm. There was marked tenderness and pain 
on the slightest motion. The swelling increased. The arm became reddened and a 
diffuse erysipelas was diagnosed. The temperature increased to 105.8°. 

Treatment. — Local treatment consisting of evaporating cooling lotions; lead 
and opium wash and bichloride were used without any marked benefit. Crede 
ointment was rubbed into the axillary glands several times a day. An injection of 
10 cubic centimeters of antistreptococcus serum (Aronson) seemed to have very 
good effect. The cooling lotions were continued, but within twenty-four hours after 
the serum injection the temperature came down by lysis and after four days the 
temperature was normal. The case recovered. 



CHAPTER XL 
VARIOLA (SMALLPOX). 

This acute infectious and contagious disease is frequently seen in un- 
vaccinated children. It is rarely met with in children that have been prop- 
erly vaccinated. I have seen smallpox in very young infants and children 
that were unvaccinated during my service at the Riverside Hospital in the 
summer of 1902. 




Fig. 204. — Two children in the Municipal Hospital of Philadelphia, one 
unvaccinated, and the other vaccinated on day of admission; the crust still 
visible on the leg. This child remained in the hospital, with its mother 
who was suffering from smallpox, for three weeks, and was discharged per- 
fectly well. The unvaccinated child, admitted with smallpox, died. (From 
"Acute Contagious Diseases," Welch & Schamberg.) 

Etiology. — The etiological factor, most likely a specific micro-organ- 
ism, has not yet been found. 

Among unvaccinated children between 1 and 10 years of age, some 
authors state that 58 per cent. die. During the Sheffield epidemic, of 
2892 unvaccinated children under 10 years of age living in infected 

(638) 



VARIOLA. 



G39 



houses, 7.8 per cent, were attacked. During the Warrington epidemic 54.5 
per cent, of unvaccinated children under 10 years of age were attacked. 

It is a curious fact that the resistance of children is less than that of 
adults. Nursing infants frequently have mouth, nose, and throat com- 
plications, which seriously interfere with their feeding, causing death. 

There are three types of variola: — 



Table Xo. 66. 



1. Natural 



Discrete 

-] Confluent 

L Semi-confluent 



< Discrete when the eruption is scattered 

I Confluent when the eruption is thick and 
\ flows together. 

f Serni-confluent when the eruption is discrete 
\ in some parts and confluent in others. 



2. Haemorrhage 



3. Modified. 



' Purpuric 
Hemorrhagic 
, Exudative 

{Anomalous 
Corymbose 



( Corymbose when the eruption forms groups 
I or clusters on various | arts of Ihe body. 



The mode of infection is most probably a micro-organism which exists 
either in the vesicles, pustules, or crusts. It may be carried in the air so 
that infection may take place at some distance from the body. Some au- 
thors believe that the blood of smallpox patients contains the poison. Small- 
pox can be transmitted directly from person to person. It can also be trans- 
mitted from bedding or clothing worn by an infected person. Entering a 
room during the pustular and desquamative stages is sufficient to commu- 
nicate the disease. 

Symptoms. — In young children the disease is usually ushered in with 
convulsions. The pulse-rate ranges between 130 and 160. The respira- 
tion is labored and increased in frequency. 

Curschmann believes that these symptoms are due to an irritation of 
the respiratory centers. 

The temperature rises rapidly and continuously without the morning 
remission. Beginning with 102° or 103° F. on the first day of illness, the 
temperature soon reaches 105° F. (40.5° C.) until the eruption appears. 

With the first appearance of the eruption, the temperature frequently 
drops to normal. This symptom of fever occurs in no other exanthematous 
eruption. 

The Eruption. — "Keddish specks or dots developed into papules re- 
sembling flea-bites appear about the second day. After the papules have 



640 



THE INFECTIOUS DISEASES. 



attained the size of a small pea their summits gradually assume a trans- 
lucent glazed appearance which indicates the formation of a vesicle. As 
this enlarges a central depression or umbilication takes place which is 
looked upon as characteristic of the smallpox lesion. If punctured a small 
amount' of mucilaginous serum exudes. The eruption is not confined to 
the skin, but is met with in the mucous membrane on the mouth, throat, 
and nose. 



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Fig. 205.— Temperature Curve in Variola. (Original.) 



Stage of Suppuration.— On the sixth day of the eruption there is a 
decided yellowish tint, due to the presence of pus cells or polymorphonuclear 
leucocytes resembling cream. The face usually presents an erysipelatous 
redness. 

Stage of Decline.-— About the twelfth day of the eruption there is a 
spontaneous rupture of the pustules. . After the contents are thus evacu- 
ated, or by absorption, we see evidences of desiccation. The pustular con- 
tents dry up and the pustule dies, leaving a blackish crust. These blackish 
or brownish crusts appear first where the eruption took place. We there- 
fore first note this condition on the arms, palms, and soles. The crusts 
separate from the body between the sixteenth and twenty-first days. 

Desquamation of a furfuraceous character takes place, lasting from 



VARIOLA. 



641 



one to two weeks. After this condition has disappeared the patient may 
be regarded as cured. 

Differential Diagnosis. — Corlett describes the great resemblance of 
smallpox to typhoid fever in its early stages, in a case seen by him. A 
strong Widal reaction was found, besides a bronchitis. 

Measles frequently resembles smallpox. Catarrhal symptoms always 
present in measles are absent in smallpox. The lesions in measles are 




Fig. 206.— Smallpox in a Child that was Vaccinated During the 
Incubation Period. Vaccination performed five days before the appearance 
*of the variolous eruption. Little or no modification. (Kindness of Dr. 
J. F. Sehamberg.) 

flat, soft, and velvety to the touch. The papules of smallpox are small 
and feel like shot imbedded in the skin. 

Scarlet fever sometimes resembles variola of a mild form. The 
premonitory symptoms of variola are very severe, and last two or three 
days, whereas those of scarlet fever are mild, last a few hours, and not in- 
frequently are entirely overlooked. The rash in scarlet fever appears on 
the upper part of the body, chest, cheeks, and neck. In variola a scar- 
latinal form of eruption is seen on the lower part of the abdomen and on 
the inner surface of the thighs. It is bright and fiery red in scarlet fever 
and dull red in variola. The conspicuous papillae or strawberry tongue is 
present in scarlet fever and absent in smallpox. 

Impetigo is frequently mistaken for smallpox. Corlett describes the 
presence of supposed impetigo in Ohio in 1898 which gave rise later on 



642 ™ E INFECTIOUS DISEASES. 

to an epidemic 01 smallpox. Thus it is apparent that there is a great 
resemblance between impetigo and smallpox, and vice versa. 

Chicken-pox is frequently mistaken for smallpox. I have already out- 
lined the differential points in describing chicken-pox (see chapter on 
"Varicella"). 

Syphilis may sometimes be mistaken for variola. A study of the 
temperature and pulse and careful observation for several days will 
usually clear up the diagnosis. In variola the eruption assumes a pus- 
tular character on the palms and soles. 

The Prognosis and Course are always bad in unvaccinated children, es- 
pecially in the very young. In the vaccinated the prognosis is always good. 

A series of cases was seen by me, during the summer of 1902, in the 
smallpox wards of the North Brothers' Island Hospital. Out of twelve 
children seen not one had been vaccinated. One child was infected by 
its mother. 

As a rule the course extends over three weeks, rarely lasting four weeks. 
Complications of the nose, mouth, and throat of a catarrhal nature are 
occasionally seen. The outcome of the cases seen by me was quite good 
in spite of the severe character of the disease. 

Complications. — Swelling of the mucous membrane, such as oedema of 
the glottis, bronchitis, and broncho-pneumonia, frequently complicates 
variola. The eruption plus secretion, when present in the throat, are the 
cause of great irritation, and give rise to a hacking cough. Suffocatory 
symptoms may follow oedema of the glottis. Otitis of a purulent nature 
is frequently seen. It is usually accompanied by severe neuralgic pains. 

Treatment. — The best sanitary surroundings, fresh air, and the strict- 
est possible isolation are advisable. The local application of a solution of 
glycerine and carbolic acid will tend to relieve the itching, and to soften the 
crusts. 

The bowels should be kept thoroughly cleansed, and the patient made 
comfortable by a tepid pack if the temperature is high or if delirium is 
present. An ice-cap and cold colon flushing will render the patient more 
comfortable. If cardiac depression exists, stimulation with musk, cam- 
phor, or champagne is advisable. Eegarding sanitary measures the New 
York Health Department requires the immediate removal of a case of this 
kind to the smallpox hospital. The disinfection and thorough fumiga- 
tion of everything which was in contact with the case must be remem- 
bered if we wish to prevent the spread of the disease. 

• Varioloid (Modified Smallpox). 

The symptoms are milder, the papules less in number, and the gen- 
eral condition shows an infection of a lesser type than we see in variola. 



VARIOLA. 



643 




Fig. 207.__ Mild Di screte Smallpox in an Unvaccinated Girl. Note 
absence of lesions upon the trunk. (Kindness of Dr. J. F. Scham- 

berg.) 



644 THE INFECTIOUS DISEASES. 

The febrile symptoms may be the same as we see in true smallpox. The 
attack is shorter. The severity of the symptoms depends on the length of 
time since the last vaccination took place. 

Vaccination" (Vaccinia) . 

This disease can be induced by inoculating the arm or leg with bovine 
or human virus. By inducing this disease we protect against smallpox. 
The serum employed is usually taken from a calf suffering with vaccinia or 
cow-pox. By inoculating the body with this cow-pox we produce an im- 
munity which protects against smallpox. During my service at the River- 
side Hospital, I have frequently seen infants that had never been vaccinated 
suffering with smallpox. I have never seen a case of smallpox in an infant 
previously vaccinated. 

When we consider the ease with which we can confer immunity and 
protect the human body against smallpox, then it seems nothing less than 
criminal to permit an innocent human being to go about unvaccinated. 

Symptoms. — From five to ten days after inoculation a red areola is 
seen around the wound. Inflammatory symptoms are marked. The 
neighboring lymph glands are swollen. An eruption resembling measles or 
scarlet fever sometimes follows vaccination. 

It usually involves the arms, neck, and chest; in rare cases it involves 
the whole body. It most commonly occurs between the eighth and eleventh 
days after vaccination. The temperature is rarely above normal and there 
is no constitutional disturbance. 

The Complications. — Eare complications are erysipelas and cellulitis. 
Abscesses are usually the result of carelessness or infection. This infection 
usually takes place at the time of inoculation or may result from dirt or 
scratching with dirty nails, or other filthy habits. (Read chapter on 
"Varicella.") 

Syphilis and tuberculosis are mentioned as accidental infections, but I 
have never seen or heard of a bona fide case resulting from vaccination. 

Varieties of Vaccine. — (a) Humanized, (b) Bovine. Humanized vac- 
cine is rarely or never used. By using human virus the chance of conveying 
syphilis or other disease has been thought possible. Therefore, the bovine 
virus has been given preference. 

Where to Inoculate. — Usually on the arm, although the leg is some- 
times preferred for females. The upper third of the arm is the part usually 
chosen. When preference is shown for vaccination on the leg in female 
infants, the lower anterior outer third should be chosen. Good vaccine 
virus will take on almost any part of the body. 

Method of Inoculation. — The parts to be inoculated should be cleaned 
with soap and water; also the operator's hands. After thorough drying of 
the parts with cotton, a sterile needle should be used for scarification. A 



PLATE XXX 




Confluent Type of Smallpox. Seventh day of vaccination. Vaccinated too 
late — during incubation period. (Courtesy of Dr. Sehamberg. ) 



VACCINIA. 645 

small area of epidermis should be removed, but no blood should be drawn. 
No antiseptic should be used to clean the part to be inoculated; otherwise, 
we destroy the vaccine virus. 

Welch and Schamberg, 1 in a series of cases, call particular attention to 
the great difference in the death-rate between the vaccinated and the un- 
vaccinated patients. Those who were vaccinated in infancy and showed 
good scars gave the remarkably low death-rate of 2.61 per cent., as against 
the high death-rate of 28.17 per cent, in the unvaccinated. There is no 
doubt that all those who showed either good or fair scars were successfully 
vaccinated. If we consider them together, the death-rate is 4.84 per cent. 

In making a comparison between the vaccinated and unvaccinated 
cases, it is scarcely fair to include vaccinated, all the cases showing poor 
scars, as very many of them, doubtless, were never successfully vaccinated. 

Patients who had been vaccinated seven days, or less than seven days, 
before the appearance of the eruption of small-pox gave a death-rate of 
35.71 per cent., while those who had been vaccinated for a longer period 
than seven days before the outbreak of the efflorescence gave a death-rate 
of only 14.28 per cent. 

Treatment. — The vaccinated area should be covered with a square piece 
of sterilized gauze held in place with strips of adhesive plaster. This dress- 
ing should not be removed for one week. In some cases a shield or protector 
containing a piece of gauze will keep the inoculated area clean and dry and 
the clothing from adhering. The rules of asepsis are very important in 
vaccination. If the skin is thoroughly scrubbed, so that no bacteria remain, 
then an infection will probably be ruled out. If, on the other hand, asepsis 
was not carried out, then vaccinal ulcers will result. 

Local treatment consists in saturating the gauze with antistreptococcus 
serum several times a day. To retain the moisture of the serum, the 
gauze is covered with oiled silk. Sexton 2 reports very successful results 
from this treatment. 

Vaccinia. 

This acute condition is characterized by an eruption following the 
inoculation of lymph. When lymph is taken from a seropurulent eruption 
on the teat or udder of a cow, it is called cow-pox. Some authors believe 
that vaccinia is a modified form of smallpox. 

Symptoms. — An eruption resembling measles or scarlet fever sometimes 
follows vaccination. It usually involves the arms, neck, and chest; in rare 
cases it involves the whole body. It most commonly occurs between the 
eighth and eleventh days after vaccination. The temperature is rarely 
above normal and there is no constitutional disturbance. There is no treat- 
ment excepting cleanliness. Internally, a mild laxative may be given. 



1 Therapeutic Gazette, June 15, 1902. 

2 Archives of Pediatrics, Feb., 1913. 



CHAPTER XII. 

TYPHOID FEVER. 

Typhoid fever is an acute infectious disease caused by the invasion of 
a specific micro-organism, known as Eberth's typhoid bacillus. 

Etiology. — Typhoid is rarely seen in infants. It is most frequently 
seen in children over 5 years of age. In a series of 97 cases described by 
Henoch : — 

2 cases occurred during the 1st year 
21 cases between the 2d and 5th years 
59 cases between the 5th and 10th years 

Von Steffens in a series of 148 cases reports : — 

2 cases occurred during the 1st year 
28 cases between the 3d and 6th years 
34 cases between the 6th and 9th years 

I have seen typhoid fever in an infant 1 year old which was infected 
by its mother. 

Baginsky describes an epidemic of typhoid seen by him in Germany 
in which 16 cases were under 10 years of age. 

Infected water and infected milk appear to have caused this disease 
more than any other factor. Baginsky mentions flies as an occasional 
source of infection. 

The New York Health Department, in a circular of information con- 
cerning the urine in typhoid fever, directs attention to the fact that "the 
typhoid bacilli are present in almost incredible numbers, estimated at many 
millions per cubic centimeter." - - 

These germs find a suitable culture medium for their' propagation in 
the intestinal tract. They are very easily found in the faeces in the living 
state during the height of the disease. 

The entrance of the typhoid bacillus into the gastro-intestinal tract, 
whether it is in food, liquid or solid, is responsible for the disease. It is 
true that a receptive condition may exist. A child having had a series of 
gastro-intestinal attacks is more liable to an infection than one whose diges- 
tive tract is normal. Bickets and a general debilitated condition certainly 
favor the development of typhoid. 

Typhoid fever occurs most frequently in the fall of the year. I have 
seen more cases of typhoid in children during September and October than 
during the rest of the year. During the fall and winter of 1902 and 1903 
some of the worst cases of typhoid with haemorrhages occurred. 

Bacteriology. — The typhoid bacillus resembles the bacillus coli com- 
munis, and is found chiefly in the lymphoid tissue of the small intestines, 
especially in Peyer's patches, where it produces a specific inflammation. 
The bacillus is found not only within the intestines, but in the glands as 
well. Neuhaus found the bacillus by puncturing the roseolar eruption 
and examining the blood therein. It has also been found in laryngeal 
(646) 



TYPHOID FEVER. 



647 



ulcerations during typhoid. The bacillus was also found in the purulent 

meningitis accompanying typhoid, so that we can be reasonably certain 

that the bacillus abounds in almost every part of the body. The action 

of typhoid bacillus on the human system is 

toxic. Brieger isolated a poison from the 

typhoid bacillus, which is called the typho- 

toxin. 

Pathology. — The pathological findings 
consist in an inflammatory condition of the 
mesenteric glands ; besides these the solitary 
and agminated glands of the ileum and colon 
not only show evidences of swelling, but 
when the disease progresses it frequently ter- 
minates in ulceration and necrosis. 

Occasionally the glands will show a 
softening and pus will develop. The spleen 
is usually very large and soft, and quite pal- 
pable. When the disease lasts several weeks 
and there are evidences of a distinct toxaemia, 
the poison will cause a marked degeneration 
of the kidneys and liver, also affecting the 
heart muscles, which, later, will be found 
very soft and flabby. 

Morse 1 reports several cases of foetal and 
infantile typhoid. 

Foetal and Infantile Typhoid. — In re- 
gard to foetal typhoid he says that the ty- 
phoid bacillus can transverse the abnormal, 
and possibly the normal placenta from 
mother to foetus. Other organisms may also 
pass in the same way. 

Infection of the foetus results. Because 
of the direct entrance of the bacilli into the 
circulation, intrauterine typhoid is from the 
first a general septicaemia. For this reason, 
and possibly also because the intestines are 
not functionating, the classical lesions of 
intrauterine typhoid are wanting. 

The foetus usually dies in utero or at birth as the result of the typhoid 
infection. 

' It may be born alive but feeble and suffering from the infection. If 
so, death occurs in a few days without definite symptoms. 

1 Archives of Pediatrics for December, 1900, 




Fig. 208. — Typhoid Infantum 
in a 2-Year-Old Boy. (a) Soli- 
tary follicle; fb) small agmin- 
ated gland; (c) Peyer's patch. 
General medullary infiltration, 
no ulceration. Natural size. 
(Langerhans.) 



648 THE INFECTIOUS DISEASES. 

It is possible that the foetus may pass through the infection in utero 
and be born alive and well. There is, however, no proof that this happens. 

Infection does not always occur. The pregnant woman does not neces- 
sarily transmit the disease to her child. 

As to infantile typhoid Morse concludes that except for the lessened 
exposure in the first year through food there seems no obvious reason why 
typhoid should be less frequent in infancy than in later life. Nevertheless, 
judging from the small number of cases reported, it is less frequent. It may 
really be less frequent, or only apparently so because the disease is not recog- 
nized, being mistaken for other conditions. Bacteriological examinations in 
large series of autopsies on infants and the use of the Wiclal serum test in 
large numbers of sick babies seem to offer the best means for determining 
both the frequency and the character of the disease at this age. 

The accuracy of the diagnosis in many of the earlier reported cases 
must be regarded as very doubtful, and hence no satisfactory conclusions 
can be drawn from them. Analysis of the more recent and certain cases 
seems to show that the symptoms of infantile typhoid are essentially the 
same as in adults, but that the course is shorter and the mortality greater. 
These conclusions may be inaccurate, however, as it is possible that they 
are based on the severe cases alone, the milder cases having escaped notice. 
The pathological changes in the intestines are, as a rule, insignificant. The 
contrast between them and the severity of the general symptoms is striking. 
The probable explanation is that in the infant as in the foetus, but to a less 
degree, the disease is a general rather than a local infection. 

The serum reaction occurs in infantile as in adult typhoid. There are 
no data as to whether or not it occurs in foetal typhoid. 

Immunity. — The agglutinating power may or may not be present in 
the blood of infants born of a woman with typhoid. If present, it is trans- 
mitted from the mother to the child through the placenta. It is possible, 
however, that it may be formed in the child in response to toxins trans- 
mitted through the placenta. The agglutinating principle can pass through 
the normal placenta. Part of it, however, is arrested in the passage. 
Whether or not it is transmitted seems to depend on the strength of the 
agglutinating power in the maternal blood and the length of time during 
which the placenta is exposed to it. 

It may be transmitted to the nursling through the milk. It may appear 
in the infant's blood in less than twenty-four hours. It lasts but a few 
days after the cessation of nursing. It is always weaker in the milk than 
in the maternal blood and always weaker in the infant's blood than in the 
milk. This weakening of the agglutinating power is due to the obstruction 
to its passage in the mammary gland and in the nursling's digestive tract. 
The chief factor governing transmission is the intensity of the power in 
the maternal blood. 'A subordinate but important factor is pome unknown 



TYPHOID FEVER. 549 

condition in the digestive tract. If the power in the maternal blood is 
weak and the obstacles great it may not be transmitted. 

Symptoms. — The symptoms are usually very obscure in children. 
Vomiting and sometimes diarrhoea are the earliest symptoms. In other 
cases constipation may be an early symptom. The so-called pea-soup diar- 
rhoea seen in adults and older children is rarely met with in young infants. 
Convulsions frequently usher in an attack of typhoid fever. 

In older children, those able to complain will usually give subjective 
symptoms, which may aid materially in making the diagnosis. A constant 
headache, for example, will always show a severe form of infection, and 
may be the only symptom which will be constant. 

The j>eriod of incubation varies from five to fourteen days. "We can 
safely say it is rare for the period of incubation to extend over three weeks. 

The Temperature. — The temperature is one of the main indications 
of typhoid. It rises at night and falls in the morning, the morning fall 
being less and the evening rise greater for the first week (step-laddder type) 
until the maximum is reached. The temperature shows fairly regular oscil- 
lations, morning fall and evening rise for about a week. It then returns 
to normal at the end of the third, sometimes at the end of the fourth or fifth 
week. The temperature drops by lysis, never by crisis. 

Secondary fever is rare in children. It is not unusual to find a mild 
form of typhoid terminating normally at the end of two weeks. 

During the second week of the disease when the temperature remains 
fairly constant, the diagnosis will be much easier, although a positive diag- 
nosis from the temperature alone should not be made. The temperature in 
a mild form of typhoid in an infant varies between 101° and 103° F. during 
the first week, or even the second week, of the disease. Severe cases may 
show a temperature of 105° F., or even higher, during the first week of 
the illness. The temperature may show peculiar variations. We may have 
a sudden rise extending over a period of six weeks instead of three weeks. 
This prolonged pyrexia sometimes denotes complications. If the tempera- 
ture has ranged between 103°, 104°, or 105° F., and suddenly drops to 
normal or subnormal, then we must suspect either an internal haemorrhage 
or look for a perforation. Sudden variations in the temperature, as a very 
sudden rise or fall, must always be looked upon with suspicion. There is 
no crisis in typhoid as there is in pneumonia. 

The Pulse. — The pulse is usually increased in frequency and ranges 
between 130 and 160 per minute. The force and rhythm are good unless 
some complication arises. The pulse is usually small and compressible, and 
there is very low tension in fatal forms of the disease. 

The Tongue. — The tongue is coated with a whitish, more rarely a 
brownish, fur. This coating extends down the center, although the whole 



650 



THE INFECTIOUS DISEASES. 



tongue may be covered. The month appears very dry, and the patient 
sometimes complains of intense thirst. 

The abdomen is nsnally distended with gas and there is marked tym- 
panites on percussion. Gurgling and tenderness on palpation in the ileo- 
cecal region is not to be looked upon as an important symptom. 

The Spleen. — The spleen cannot be relied upon as a diagnostic aid in 
children. While it may be enlarged in some instances, we frequently find 
that it is not palpable in many cases of severe typhoid. 

Coughs and Bronchial Catarrh. — One of the earliest symptoms in ty- 
phoid is bronchitis. In the beginning when we have but cough and fever 
the diagnosis will be quite difficult. Typhoid frequently simulates pneu- 

The Nervous System. — In profound tox- 
icity the nervous symptoms present will be 
muttering, delirium, and a semi-comatose 
condition. Not infrequently rigidity of the 
muscles of the neck is present, so that the 
differential diagnosis from meningitis will 
be difficult. The nervous symptoms fre- 
quently resemble those seen in tubercular 
meningitis. Acute tuberculosis may some- 
times resemble typhoid. 

Extreme Emaciation. — Children fre- 
quently show emaciation during typhoid for 
the following reasons : — 

1. The constant fever. 

2. The low vitality owing to mal- 
nutrition. 

3. The system being constantly drained when diarrhoea exists. 

Diagnosis. — In every case of fever in which a diagnosis cannot be made, 
a drop of blood should be examined for the presence of the Widal reaction. 
This reaction is always a trustworthy evidence of the presence of typhoid, 
and a negative reaction later than the tenth day is strong but not absolutely 
convincing evidence of the absence of typhoid. The test is of greater 
value in the case of an infant than an adult, as we can exclude the occurrence 
of a previous attack. Some writers state that the reaction is seen earlier 
in children than in adults. 

It should not, however, be the only means of making a diagnosis. It 
is well known that this reaction will occur months and sometimes years 
after the patient has recovered from typhoid, hence great caution should be 
used in relying on this diagnostic measure exclusively. 

Widal Test for the Diagnosis of Typhoid Fever. 1 — The investigations 




Fig. 209. — Stages in Widal 
Eeaction. (After Robin. ) 



1 This method is described by the New York Health Department. 



TYPHOID FEVER. 651 

of Griiber, Widal, and others, published in 1896, showed that the blood 
of persons, suffering from or having recently had typhoid fever, contains, 
as a rule, after the fifth day of the disease, substances which, when added 
to a broth culture of the typhoid bacilli, arrest the characteristic move- 
ments of these organisms and cause them to become clumped together in 
masses. 

The results of a very large number of examinations made here in Xew 
York and elsewhere show, that if the blood contains agglutinating sub- 
stances in sufficient amount to cause a prompt and marked reaction, when 
one part of serum or blood solution is added to 10 parts of a broth culture 
of the typhoid bacillus, the presence of a previous or existing typhoid in- 
fection may be considered as extremely probable, and that if these sub- 
stances are present in such an amount as promptly to produce the reaction, 
when 1 part of serum or dried blood solution is added to 20 parts of the 
culture, the presence of a previous or existing typhoid infection may, for 
diagnostic purposes, be practically considered as established. 

In estimating the diagnostic value of a negative result from this test, 
we must remember that the reaction is rarely, if ever, present until at least 
four days after the appearance of symptoms; that it is occasionally absent 
in cases of typhoid fever until the third or fourth week, or even until con- 
valescence is established; that when developed it may disajmear after a 
few days, and that no definite relation between the severity of the disease 
and the degree and time of development of the substances causing the 
reaction has been established. For these reasons a single negative result 
in any suspected case only renders doubtful the existence of typhoid fever. 
In those cases in which the reaction is absent after the ninth day, it may 
be reasonably assumed that the large majority will not prove to be typhoid 
fever, and the absence of the reaction in all of several different cases of a 
suspected group, or after repeated examinations in any single case, affords 
evidence of very decided value in excluding the diagnosis of typhoid fever. 

Directions for Preparing Specimens of Blood. — The skin covering the 
tip of the finger is thoroughly cleansed and then pricked with a clean 
needle deeply enough to cause several drops of blood to exude. Two large 
drops are then placed on the glass slide, one near either end, and allowed 
to dry without being spread out on the surface of the slide. After they 
have dried, the slide is placed in the holder and returned in the addressed 
envelope to a culture station, or mailed to the laboratory. 

The diazo reaction should be looked upon as a valuable aid in making 
the diagnosis. It is described in detail in the chapter on "Urine," page 883. 

The Eruption. — The eruption consists of lenticular-shaped, rose-col- 
ored spots. They are small and slightly elevated. These rose-colored spots 
appear at the beginning of the secoud week. The eruption lasts about ten 
days, although the spots last from two to three days and are succeeded by 



652 



THE INFECTIOUS DISEASES. 



a new crop. They are seen on the thorax and abdomen, although at times 
over the whole body. 

Leucopcenia if present strongly supports the diagnosis of typhoid. In 
the International Clinics 1909, I report a series of cases in which the white 
blood cells ranged between 4000-6000 at the beginning of the disease. 

Differential Diagnosis. — Malaria frequently resembles typhoid. A dif- 




Fig. 210.. — Typhoid Fever. — Severe haemorrhages. Fatal result. (Original.) 



ferential diagnosis can easily be made by an examination of a drop of blood 
for the presence of plasmodia. 

The administration of quinine is a diagnostic test of practical im- 
portance. An irregular or intermittent fever which yields promptly to 
quinine is certainly not typhoid. In malaria, the temperature will be found 
to touch normal at some time in the twenty-four hours. 

Cholera Infantum. — Many cases of supposed cholera infantum fre- 
quently prove to be typhoid fever. I have seen many cases in midsummer 



TYPHOID FEVER. 653 

with a temperature of 102° F., having roseola, with vomiting and diar- 
rhoea. In such cases the diagnosis depends on the presence of the Widal 
reaction. 

When .diarrhceal symptoms and fever are present in the early stages 
of typhoid fever it is extremely difficult to make a diagnosis. This applies 
especially to the first week of the disease before a Widal reaction can be 
made. I have invariably examined the urine for the presence of indican 
(see page 880). When the symptoms are due to intestinal autointoxication 
or fermentative conditions in the intestine, then a positive indican reaction 
is present. If the diazo-reaction is absent and indican present, we can 
exclude typhoid fever. 

Internal Hcemorrliages. — Holt reports a series of 946 collected cases 
in which haemorrhage occurred in 30 cases, about 3 per cent. The ma- 
jority of these cases were over 10 years of age. I have frequently seen 
haemorrhages in children between 5 and 10 years ; never under 5 years. 

Case I. — A ease of typhoid in a boy 16 years old, seen in consultation with Dr. 
Rayewsky, had a series of haemorrhages which ended fatally. The origin of this case 
was supposed to be an infection from eating raw oysters. The boy was a telegraph 
messenger and ate some oysters in the street, after which he showed signs of fever, 
and intestinal symptoms. No other etiological factor was ascertained. The boy 
was in good health and suddenly became ill after eating this meal of oysters. Symp- 
toms of gastric fever, with diarrhoea; temperature of 101° to 103° F. gradually 
appeared. The symptoms increased from day to day until delirium and general coma 
were present. The fever was difficult to control in spite of cold tub bathing. The 
boy weakened from constant pyrexia — appeared to convalesce — when a severe haemor- 
rhage occurred. An ice-bag was laid over the abdomen, and opium given internally. 
The colon was flushed with alum and water. Nothing seemed to control the bleeding. 

Case II. — A girl, 10 years old, was seen in consultation with Dr. H. Wein- 
stein. She had been sick about three weeks when seen by me. She was apparently 
convalescing when she had a haemorrhage of a very alarming nature. The doctor 
told me the child lost more than one pint of blood. The pulse was about 130 and 
very feeble in character. The child was deathly pale and seemed to be in collapse. 
Whisky and strychnine were ordered as restoratives. The child complained of chills 
and was thoroughly wrapped in warm blankets and hot-water bottles were applied 
to her feet. A teaspoonful of powered alum added to a pint of cold water was in- 
jected into the rectum and colon. Paregoric in 15 drop doses was ordered every hour. 
The nurse was instructed to watch the pupils and the pulse and to discontinue the 
drug as soon as the systemic effect of the paregoric was manifested. Ice-cream was 
ordered internally and small pellets of cracked ice. The child recovered after 
careful dietetic and restorative treatment. 

Intestinal Perforation. — Intestinal perforation is very rare. It is met 
with in about 1 per cent, of all cases. A sudden fall in the temperature 
with collapse, rarely vomiting, followed by tympanites, are symptoms indi- 
cating perforation. 

Laparotomy When Perforation Occurs. — The skill of the surgeon will 
frequently save life when haemorrhages occur. In a case of typhoid which 



654 THE INFECTIOUS DISEASES. 

progresses favorably during the third and fourth week, a- sudden collapse 
should be an indication for an immediate operation. I have seen death 
follow a case of this kind. These cases are usually hopeless and our only 
chance consists in resorting to an immediate operation. 

Complications. — Aphasia is occasionally met with. Morse reported 21 
cases. Insanity is rarely met with as a sequel to typhoid. Chorea is fre- 
quently seen. I have met with a case having a severe form of choreiform 
movements which lasted more than a year, following the attack of typhoid. 

Otitis media is frequently met with in children. It is very important 
to watch the ears during an attack of typhoid. 

Less frequent complications are gangrenous inflammation of the mouth 
or genitals, pericarditis, endocarditis, peritonitis, pysemia, abscesses, and 
furuncles. Abscess of the liver has been reported by Bokai. Pulmonary 
tuberculosis has been known to follow typhoid. 

Prognosis and Course. — The prognosis is more favorable in children 
than in adults. Tympanites, if accompanied by vomiting, is a bad sign. 
When there is general depression and nervous symptoms then the prog- 
nosis is bad. Singultus is usually a bad sign. Bleeding should always be 
looked upon, especially if repeated, as a bad sign. The strength 
of the child, its assimilation of food, and the condition of the heart should 
be the means of arriving at the proper prognosis. Complications should 
always be regarded as a serious matter. The prognosis is grave if the 
child has passed through a typhoid and is in an exhausted condition, and 
unable to cope with a new complication. Baginsky states that in a series 
of 68 cases treated by him in the hospital, 6 died, a mortality of 8.8 per 
cent. 

In children typhoid may terminate in two weeks. It may extend 
over three weeks or even four weeks. Mild cases of typhoid resem- 
ble an attack of acute gastric fever. Cases are occasionally seen in which 
the disease terminates abruptly within ten days. As a rule older children 
show the adult type of fever and the disease runs its course of three, four, 
or six weeks. Infantile typhoid may show severe gastric symptoms, such 
as vomiting, and very little diarrhoea. The course, therefore, is peculiar to 
infants and entirely different from that "seen in the older child. 

The following case was seen by me some time ago. A woman, 35 years of age, 
was taken ill with typhoid fever of a very severe type. She nursed her infant during 
the first week of her fever. The infant was then 1 year old. The physician ordered 
the infant weaned. About one week later the infant had fever, vomiting, and diar- 
rhoea. An examination of the blood gave a positive Widal reaction. The infant 
recovered in about fifteen days. The mother died of haemorrhages during the third 
week of her illness. 

Treatment. — The specific nature of the disease due to the infection 
of a specific germ, has caused investigators to seek a typhoid antitoxin. As 
yet no definite progress has been made in this direction, although inves- 



TYPHOID FEVER. 655 

tigators have from time to time announced the discovery of a healing serum. 1 
In the absence of a specific serum we must confine ourselves to the treat- 
ment of indications. In the beginning a good dose of calomel, 1 / 2 to 1 
grain, repeated several times a day, is indicated. 

Fever Treatment. — The best antipyretic is the cold bath and cold pack. 
The bath must be properly given to be effective. A large bath-tub should 
be procured, large enough to hold the child at full length. This should 
be half-filled with water at a temperature of 90° F. Cold water or, in 
summer, ice should be added until the temperature is gradually reduced 
to 70° F. This is an agreeable method, as we avoid the sudden shock so 
dreaded by children when suddenly immersed in cold water. The dura- 
tion of the bath should be from three to five minutes. 

The temperature of the child should be taken before and after the 
bath. The child's body should be rubbed continuously while in the bath 
so as to stimulate the circulation, especially so when the water is cool. If 
the child's pulse is feeble, administer a stimulant such as hot coffee or 
whisky before the bath. Watch the pulse carefully, and if the slightest 
sign of weakness is noted, remove the child immediately from the bath 
and place in bed with hot-water bottles to its feet. The bath should be 
repeated every three or four hours or oftener, if the temperature requires 
it. If the temperature is not modified lower the temperature of the bath. 

Antipyretic drugs, such as napthaline, benzoate of soda, quinine, anti- 
pyrin, antifebrin, phenacetin, and lactophenin, are useless in combating 
fever when compared to cold baths and cold packs. All antipyretic drugs 
of the coal-tar series are such cardiac depressants that they should never 
be prescribed without combining them with camphor or musk. Of all anti- 
pyretic drugs I prefer phenacetin. One of the best antipyretic measures is 
the injection of several pints of cold saline solution through a catheter into 
the colon. Too much hydrostatic pressure should not be used. The irri- 
gator should be held about one foot Over the child's body; the temperature 
of the water should be between 60° and 70° F. Flushing the colon with 
cool saline solution may be repeated every three or four hours if a good 
effect is apparent. When great exhaustion and a weak pulse exist, then 
1 / 2 teaspoonful or a teaspoonful of alcohol may be added to the irrigation. 
The main point to remember in the treatment is to support the child so 
that the strength will be maintained and the heart's action not im- 
paired. With this object in view nothing is better than restoring vitality 
by the aid of concentrated food. When there is great exhaustion the admin- 
istration of a normal salt solution per rectum, or its use by hypodermoclysis, 2 
should be remembered. One or two pints of saline solution administered 



1 Einhorn, of New York, has reported beneficial results from the use of anti- 
typhoid serum. 

2 This is illustrated in detail in the chapter on "Scarlet Fever Treatment." 



656 THE INFECTIOUS DISEASES. 

per rectum, with the hips elevated, is frequently the means of stimulating 
diuresis, thus eliminating the poisons of the toxins through the kidneys. 
Great care is required in giving the saline in the form of hypodermoclysis. 
The strictest asepsis should be maintained. A large aspirating needle 
attached to a fountain syringe (Fig. 198) is well adapted in an emergency. 
These saline injections may be repeated every six or twelve hours if required. 

Hygienic Measures. — Owing to the infectious nature of the discharges 
passing from a typhoid patient, the prime requisite is the thorough disin- 
fection of all stools and urine. If there is cough or sputum, the same must 
also be thoroughly disinfected. In fact all discharges should be received 
in a vessel containing a strong solution of javelle water (chlorinated lime) 
or a 5 per cent, carbolic solution. A strong solution of copperas should be 
thrown into the toilet from time to time while a typhoid patient is in the 
house. All bed linen, handkerchiefs, and dishes coming in contact with 
the patient should be soaked in a bichloride solution for at least one-half 
hour before being washed. Sunlight is of the greatest importance in a 
room having a typhoid patient. We can do more disinfection with sunlight 
and fresh air than we can with medication. 

The Food. — All food must be liquid ; no solid food should be allowed. 
In the beginning whey, strained soups, and broths should be ordered ; later 
strained gruels, cocoa, acorn cocoa, and chocolate may be given at intervals 
of two or three hours. In some cases albumin water, made by beating the 
raw whites of two eggs with sugar and water, is useful. I frequently give 
the whites of six eggs per day. Milk, buttermilk, kumyss, whey, or 
junket may be given, alternating with soups and broths. When stimulation 
is required the yolk of egg can be combined with sherry' or Tokay wine. 
When drugs are given it is best to combine them with soups or broths. 
When severe dyspeptic symptoms exist, predigested milk, peptonized with 
the aid of pancreatin and soda, must not be forgotten. When milk idio- 
syncrasies exist, then the yolk of a raw egg added to barley water, rice 
water, or almond milk (made by blanching almonds with hot water) can be 
substituted for milk. When thirst exists, unfermented grape juice or 
water acidulated with dilute phosphoric acid or dilute hydrochloric acid 
is very grateful.- Ten drops of either dilute acid can be added to a 
tumblerful of sweetened water, and this given whenever the child is 
thirsty. These acids have a very good effect on febrile affections, and 
are especially indicated when diarrhoea exists. 

Feeding in Convalescence. — The great danger of haemorrhage should 
always be borne in mind ; hence it is advisable to abstain from giving solid 
food for several weeks after convalescence is thoroughly established. Soups 
thickened with sago, farina or barley, and pea and lentil soups can be given. 
The yolk of a raw egg can be added to the soup. Milk may be thickened 
with zwieback. The main diet should be milk and cocoa or chocolate. 



TYPHOID FEVER. 657 

Soinatose may be added to milk or soup. Plasmon is also beneficial. 
Bovinine, liquid peptonoids, panopeptone, eucasin, or tropon, in teaspoonful 
doses added to milk, are very valuable during the convalescent period. 
Valentine's meat juice given in milk or soup is nutritious, or Mosquera's 
liquid beef (made by Parke, Davis & Co.) can be added to each soup or 
milk-feeding. 

Drug Treatment. — If cerebral symptoms exist, then an ice-bag should 
be applied to the head. When there is severe restlessness and insomnia, 
with twitchings of the muscles, then injections of 3 to 5 grains of chloral 
hydrate should be tried per rectum. These injections are best given in 
starch water. Five-grain doses of sulphonal or trional, repeated in two 
hours if necessary, is sometimes very effectual. If there is no effect, then 
V24 grain of morphine may be administered hypodermically for a child 2 
years old. 

If the child is 1 year old, then 1 / 48 grain may be given, and repeated 
in several hours, if necessary. The greatest care must be maintained if 
haemorrhage exists. 

Bismuth is a very valuable drug; the subnitrate in 5 to 10-grain doses, 
and the beta-naphthol, in 5 to 10-grain doses, may be repeated every few 
hours as an antifermentative. 

Tannalbin or tannigen, in doses of 5 to 15 grains, can also be given 
every two hours. If the haemorrhage is very severe, then an injection con- 
taining 30 drops of MonselFs solution added to a quart of cool water, or 
a teaspoonful of alum, may be added to a pint of water. These injections 
can be repeated every three or four hours until the haemorrhage ceases. 
Ice-bags should be kept continuously on the abdomen at the slightest sign 
of haemorrhage. 

Guaiacol carbonate, in 5 to 10-grain doses, repeated every three or 
four hours, is a very good antipyretic. Creosote carbonate, 1 drop for 
each year ; for a child 1 year old, 1 drop ; for a child 5 years old, 5 drops, 
three times a, day, is one of the best intestinal antiseptics. 

When severe tenesmus, associated with flatulence and very loose stools, 
exists, then the best remedy will be 1 or 2 -drop doses of turpentine, com- 
bined with several drops of paregoric. The oleoresin of turpentine in 1 
or 2-grain doses, can be combined with 1 / 10 grain of extract of opium for 
a child, 5 years old, in the form of a suppository. This can be repeated 
several times a day if the symptoms are not improving. 

Prophylaxis. — The injection of typhoid vaccine as a prophylactic has 
been described in Part VII, page 445. 



42 



CHAPTEK XIII. 
ERYSIPELAS. 

This is an acute infectious and contagions disease. It is characterized 
by an inflammatory condition of the skin, the subcutaneous tissue, the 
lymph spaces, and the lymph vessels. 

Etiology and Bacteriology. — We are indebted to Pehleisen for a study 
of the bacteriology of this disease. Fehleisen found the streptococcus 
present, so that it is positively identified as the cause of the same. The 
disease may also originate from a staphylococcus aureus. 



Fig. 21.1. — Ectogenous Streptococcus Infection. Eczema and erysipelas 
of the scalp in a child 1 month old. (Bacteria carmine stain) ; (a) cutis; 
(6) subcutis ; (c) lymph vessels filled with streptococci, surrounded by an inflam- 
matory area ; {d) epithelial covering; (e, /) elevated horny layer; (g) strep- 
tococci. X50. (Ziegler.) 

The invasion of the micro-organism takes place through an abrasion 
of the skin caused by scratching with a dirty finger-nail. It is very rarely 
epidemic, but can spread easily from patient to patient. A case of ery- 
sipelas is a source of great danger in a hospital ward. 

• (658) 



ERYSIPELAS. 



659 



Pathology. — There is an infiltration of the tissues and they are usually 
swollen from an accumulation of serum. Under the microscope we can find 
pus cells in the serum. When this condition is noted abscesses will be 
found. In other cases gangrene will be present. There is nothing char- 
acteristic found in the lungs, heart, kidneys, spleen, or liver which would 
be distinctly pathognomonic. The usual conditions found in sepsis are seen 
here. 

Pneumonia is 
sometimes met with as 
a complication. 

Symptoms. — The 
usual type of erysipelas 
met with in children 
is known as erysipelas 
migrans. This is known 
as the wandering type 
because it spreads rap- 
idly from diseased to 
healthy parts. The tem- 
perature in the begin- 
ning varies from 102° 
to 103° F., and may 
rise to 104° or 105° F. 
Septic cases usually 
show a much lower tem- 
perature. I have seen 
cases of a decided sep- 
tic nature in which the 
temperature was 99° F. 
for several days. The 
pulse-rate varies between 120 and 150. The flush is of a deep red color and 
usually very shining,, 

Complications. — The oedema usually seen on the skin is a very fatal 
complication in erysipelas affecting the air passages. In such cases oedema 
of the glottis will result fatally. 

Prognosis. — This depends upon the time when the case is first seen 
and. chiefly upon the condition of the child at the time of the infection. 
If the child is well nourished and has been breast-fed, the prognosis is good. 

Treatment. — A dose of rhubarb and soda or 5 to 10 grains of phos- 
phate of soda should be given. The destructive tendency of the pathogenic 
bacteria on the blood should be remembered ; hence large quantities of nor- 
mal saline solution should be given, by injection, into the colon. The 
strictest hygienic measures must be used. The internal administration of 



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Fig. 212. — Fever Curve in Facial Erysipelas. 
(Original.) 



6(30 THE INFECTIOUS DISEASES. 

active diuretics, such as spirits nitr. chile, is indicated. The strength of 
the child should be supported with proper food, so that it can throw off 
the poison. The most effectual treatment is the local treatment, especially 
if fever exists. 

Local Treatment.— Pure alcohol, in which bichloride of mercury is 
dissolved, should be applied continuously .by saturating absorbent cotton 
and laying the same over the erysipelatous flush: — 

I£ Alcohol 2000 parts. 

Bichloride of mercury . , 1 part. 

In some cases lead and opium wash is very cooling, and will remove 
the heat from the affected parts. In severe cellulitis and erysipelatous 
inflammations excellent results have followed the use of: — 

]$ Magnesia sulphate 2 drachms 

Aqua 16 ounces 

applied as a lotion. 

Oil silk or rubber tissue should cover the wet application to prevent 
evaporation. The inunction of a 10 per cent, ichthyol ointment has been 
tried by me with some success. I regard the use of Crede ointment as a 
very efficacious remedy. 

Vaccine. — In a mild case 50,000,000 to 100,000,000 of erysipelas stock 
vaccine should be injected on the first day. Eepeat the injection every 
day until ten injections are given, or until the symptoms improve. Severe 
cases may have an initial injection of 500,000,000. 

Baby C, 6 months old, a nursing baby, was seen by me several times in 
consultation with Dr. S. Hermann, of Brooklyn. When first seen the infant had 
been ill three days. The temperature was 105° F., pulse 168, and respiration 80. 
There were marked cyanosis, vomiting, extreme weakness, and retention of urine. 
There was a marked erysipelatous flush on the vulva which spread very rapidly 
toward the abdomen and thighs. 

The inflammation on the vulva was of a deep-red color. There were thickening 
and edema, while spreading to the buttocks and up the back we could note a 
sharply defined edge. There was slight pitting on pressure. The redness seemed to 
disappear under pressure. The redness was of an erythematous character, uniform 
and not mottled. The skin was tense and shiny. The surface temperature was 
raised. The inflammation spread from the buttocks to the back, then to the thorax, 
and downward to the extremities. From the back it spread to the neck, scalp, and 
face, closing the eyes. There was marked thickening with swelling which involved 
the ears, cheeks, nose, and neck. This swelling of the face did not interfere with 
feeding. 

Three or four days after the extension of the swelling from the buttocks to 
the back, there was a marked diminution in the redness and swelling, but the new 
areas involved were considerably indurated, tense, and hot on palpation. In three 
or four days more the scalp, ears, and nose which were swollen became less shiny, 
and the swelling gradually subsided. With the reduction of the swelling and inflam- 
mation there was a marked desquamation. The arms and legs were the last to be 
involved. They went through the same process of redness and thickening which 
lasted four to five days longer. 

From the spreading nature of the disease, I believe we can classify this case 
as one of erysipelas migrans — the wandering type of erysipelas. 



ERYSIPELAS. 661 

During the course of the disease the behavior of the infant was remarkable. 
As previously stated, it was a breast-fed infant who took its nourishment at the 
regular intervals, with the same appetite as when in health. The stool was well 
digested and normal in appearance and there seemed to be no evidence of faulty 
metabolism. The infant seemed therefore to offer good resistance to its infection, 
notwithstanding the fact that the temperature remained unusually high. 

Diagnosis. — Erysipelas migrans, of unknown origin. The sanitary surroundings 
were perfect. No apparent reason for the infection. The lungs were normal, although 
the pulse-respiration ratio was markedly disturbed and suggested a pulmonary 
complication. 

The leucodescent light was tried three times a day by Dr. Hermann, the rays 
covering the affected area. Ichthyol ointment also was used without markedly dimin- 
ishing the inflammation. The local application of lead and opium wash, and other 
evaporating lotions did not seem to reduce the temperature nor to modify the 
inflammation. The swelling continued in spite of the continued use of these lotions. 

I Tiave seen excellent results during my service at the Willard Parker Hospital 
from the constant use of a saturated solution of magnesium sulphate used locally. 
In this case it did not modify the inflammation. The erysipelas continued to 
spread, so the light treatment was discontinued and serum treatment was begun. 

There was marked fluctuation in the labial swelling and a drop of pus ex- 
amined showed the presence of Staphylococcus pyogenes aureus. 

On the fourth day of illness an injection of 75,000,000 germs of a streptococcus 
stock vaccine was given. On the sixth day, 50,000,000 ; on the seventh day,. 60,000,- 
000; on the ninth day, 70,000,000 germs were injected. A decided improvement was 
noted. By this time we had obtained an autogenous vaccine and gave the first in- 
jection of 100,000,000, a second injection of 100,000,000 plus 100,000 the following 
day. On five successive days injections, each 100,000 more than the last, were given. 

On the fifth day following the first vaccine injection an abscess on the right 
labium major was incised. A general multiple furunculosis on the arms, scalp, 
thighs, and back appeared in rapid succession. A general pyemia existed. In addi- 
tion thereto a pustular eruption appeared on the face and head. Several dozen of 
these were incised and pus evacuated. 

Summary. — A reduction of the temperature was tried with lukewarm 
colonic flushings, also by means of tub baths, but without avail. 

Ichth} T ol was useless, likewise magnesium sulphate in a saturated solu- 
tion. Neither seemed to reduce the inflammation or the temperature. 

Breast feeding was continued throughout the disease, and continued 
after complete recovery. 

The streptococcus vaccines, both stock and autogenous, brought down 
the temperature by lysis, and this seemed very effectual in modifying the 
erysipelas. 

It is difficult to state whether or not the migration of the staphylococcus 
through the circulatory tract was responsible for the multiple furunculosis, 
the numerous pyemic abscesses, and the pustular eruption on the _f ace and 
scalp. 

The large dosage of the vaccine given and the non-toxic results there- 
from show the tolerance this infant had for the same. 

The child made a brilliant recovery, and is perfectly well to-day. 

I am indebted to Dr. Hermann for the clinical details of the above- 
mentioned case. 



CHAPTEE XIV. 

MALAEIAL FEVER (INTERMITTENT FEVER— PALUDAL FEVER— AGUE). 

This is a specific infectious disease due to the invasion of a distinct 
germ belonging to the class of protozoa. It is known as the plasmodium 
malarias. "The disease is contracted by the inoculation of the human sub- 
ject by the infected mosquito. The plasmodium malarias passes through 
one cycle of its development in the body of a variety of the mosquito known 
as the anopheles cleviger." 

We find this disease in Southern Eussia and in Italy; in our own 
Southern States as well. In the North of Europe and the North of Amer- 
ica it is rarely found. The disease is usually seen in swampy regions and 
where bad drainage exists. It is also seen in the tropics. The influence of 
the weather is interesting. While in summer, spring, and fall cases occur 
frequently, in extremely cold weather they are very rare. 

Bacteriology and Etiology. — Laveran, in 1880, discovered the specific 
germ which causes this disease in the blood of infected individuals. In 
America, Councilman, Abbott, Osier, and many others have confirmed 
Laveran's observations. There are several types of fever. 

First. — The middle forms: (a) tertian, double tertian (quotidian); 
(I) quartan fever and its combinations. 

Second. — The more severe, often more or less irregular fevers which 
occur in America and in Italy, most commonly at the end of the summer 
and fall, called the sestivo-autumnal fever of the Italians. The tropical ma- 
laria of the Germans. This type of fever includes the so-called remittent 
malarial fevers as well as most of the cases of pernicious malaria and other 
malarial cachexias. 

Tertian Fever. — Golgr's description and differentiation of the micro- 
organism of the tertian and quartan type of malaria have remained prac- 
tically unassailed. "If we examine the blood from a case of tertian fever 
just after the paroxysm, we find in certain of the red blood-corpuscles 
small, round, colorless bodies which appear to have a slight depression in 
the center, and when stained in dry specimens show a paler central area 
with a darker periphery. These bodies examined in the fresh specimen 
show active amoeboid movements. A few hours later the organism will be 
found to have increased somewhat in size, and to contain a few, fine, 
brownish pigment granules which dance actively under the eye, the motion 
probably being due to undulatory movements in the protoplasm. On the 
day between the paroxysms the bodies will be found to have about half- 
filled the red corpuscles. They are still actively amoeboid, and the number 
of pigment granules has considerably increased. The red corpuscle at this 
stage will be seen to be a trifle larger than its unaffected neighbors, and to 
(662) 



MALARIAL FEVER. 663 

be considerably decolorized. On the day of the paroxysm the organism has 
entirely filled and almost destroyed the red blood-corpuscle, which is rep- 
resented only by a faint pale rim about the full-grown parasite, if, indeed, 
it has not entirely disappeared. The pigment granules may show at this 
stage a very active motion, but the amoeboid movements of the organism 
as a whole are but little marked. At the time of the paroxysm an interest- 
ing change takes place; the pigment gathers together in a more or less 
solid clump, usually in the center of the organism, while the rest of the 
protoplasm looks somewhat granular and shows a suggestion of lines radiat- 
ing outward from the center. This appearance gradually changes, the lines 
becoming more distinct, until finally we see the central clump of pigment 
surrounded by from fifteen to twenty small ovoid or round glistening seg- 
ments, each one having a central more refractive spot, and resembling 




Fig. 213.— Malaria Plasmodia; Ter- Fig. 214. — Malaria Plasmodia; Trop- 

tian Type. Plehn-Chenzinsky's Stain. ical Form. Romanowsky-Nocht Stain. 

X 1000. X 1000. 

strongly the hyaline bodies which we see immediately following the chill. 
This segmentation of the organism is always coincident with the paroxysm, 
and the presence of the blood of a segmenting body is a sure indication 
that the paroxysm is present, or is about to occur. Immediately following 
the paroxysm fresh hyaline bodies appear in the red corpuscles. Though 
the invasion of the corpuscles by these fresh segments has never been 
actually observed, the evidence that this occurs is so strong that we can 
safely accept it as a fact. Besides these forms we see not infrequently small 
or large extra cellular pigmented bodies; that is, organisms resembling 
exactly those within the red blood-corpuscles, excepting that they are free 
in the blood current. 

These may be seen at times to break up into several smaller bodies, 
while at other times they may show a long, tail-like, non-motile process 



66± 



THE INFECTIOUS DISEASES. 



containing sometimes a few pigment granules. They are probably organ- 
isms which have escaped from the red corpuscles, or full-grown bodies 
which have broken up; they are considered to be degenerative forms. At 
times also we find the so-called flagellate bodies. Their development from 
the pigmented organism may indeed be observed, the pigment of the full- 
grown body becoming very actively motile, then collecting in the center 
of the organism, while several long, thread-like flagella burst out of the 
body and move actively about among the surrounding corpuscles. Some- 
times we may see one of these flagella which has broken away from the 
organism and is moving rapidly through the field. This is also thought 
by the Italians to be a degenerative process. The characteristics of this form 
of organism, which is observed in tertian fever alone, are so marked that 
with a little study of the parasite one can make a definite diagnosis of the 
type of fever from an examination of the blood alone. 



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Fig. 215. — Tertian Fever (Intermittent Fever). Typical malarial tem- 
perature, usually seen in the spring and early summer. Onset with vomit- 
ing, diarrhoea and chills, accompanied by a well-marked rigor, and coldness 
of the extremities. (Original.) 



The Parasite of Quartan Fever. — "Quartan fever is not at all common 
in this country, but in the few cases which the writer has observed the or- 
ganisms differ distinctly from the tertian parasite, and show accurately the 
characteristics described by G-olgi. Here the first stage of the organism is 
similar to that observed in tertian fever, excepting that the amoeboid move- 
ments are not so active. As the body develops, the rods and clumps of pig- 
ments are larger and darker than those in tertian fever, while the .amoeboid 
movements of the organism are relatively slight. The full-grown forms are 
materially smaller than in tertian fever, while the red blood-corpuscles, 
instead of being expanded and decolorized, appear at times shrunken about 
the bod}', and of a somewhat deeper old-brass color (messingfarbe). In 



MALARIAL FEVER. 



665 



segmentation the organism divides into from six to ten different parts in- 
stead of twenty to thirty, as in the tertian form. 

The Organisms of the /Estivo-autumnal Fevers. — "The organisms asso-. 
ciated with the sestivo-autumnal fevers have been carefully studied, but 
much remains to be done, particularly in this country. 

"There is some difference of opinion as to whether there are not two 
types of organism associated with these fevers. Some Italian observers 
divide them into the quotidian and the malignant tertian organisms. The 
differences made out by the Italians are, however, very slight, and have not 
been observed in this country. In the first place we see just after the 
paroxysm small hyaline bodies which may or may not be actively amoeboid ; 
these can sometimes be distinguished in that they are generally somewhat 
smaller and have oftentimes a characteristic ring-like appearance. In the 
early stages — during the first week, for instance — of an attack of this form, 



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Fig. 216. — Quartan Fever (Double Tertian). Onset with vomiting and 
convulsions. Convulsions usually accompany each paroxysm. Restlessness 
associated with cyanosis and coldness of extremities. These cases are usually 
seen in the late autumn. (Original.) 

we may see only the hyaline, unpigmented forms; but commonly, if we 
observe carefully, we may see some time after the exacerbation of tem- 
perature, shortly before the beginning of another, bodies which are a trifle 
larger than these smallest hyaline forms and which contain one or two very 
minute pigment granules lying near the periphery. Just before or during 
the paroxysm we may see bodies with a small central clump of motile or 
non-motile pigment granules lying usually in cells which are more or less 
shrunken and crumpled, and of a deeper color than the normal corpuscles 
(messingfarbe). These bodies are generally not half as large as the red 
corpuscles. After the first week or ten days of the disease, or after treat- 
ment has been begun, we see, however, certain very characteristic and easily 
recognizable forms which are only seen with this type of fever. These are, 
first, round or ovoid bodies about the size of a red corpuscle, a little smaller 
or a little larger, with clear, rather highly refractive, waxy-looking proto- 



666 



THE INFECTIOUS DISEASES. 



plasm, and coarse dark pigment grannies, which are nsnally collected in a 
ring or a mass in the center of the organism. The grannies are nsnally very 
■ slightly motile. At one side of the body we often see a small bib-like attach- 
ment which may show a slightly yellowish color. On examination this proves 
to be the remains of the red blood-corpnscles in which the organism has de- 
veloped. In association with these are seen crescentic bodies, the proto- 
plasm of which shows the same characteristics as that in the forms above 
described, while the pigment is collected in the middle in a similar ring 
or bnnch, and is bnt slightly motile. On the concave side of these crescents 
one may also often see a bib-like attachment, just as in the ovoid forms. 
At times during the examination of the fresh specimen we may see the 
change from an ovoid body into a crescent take place. The development of 



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Fig. 217.. — iEstivo-autumnal Fever (mild type). Ushered, in with vomit- 
ing, restlessness and flushing. The spleen is enlarged. Either delirium or 
drowsiness and somnolence exists. (Original.) 



these forms from the hyaline bodies can be followed out on careful ob- 
servation. They are thought by some to be a resting stage of the organism. 
Segmenting bodies are almost never seen in the circulating blood of this 
form of malarial fever, though the presence of the round intracellular 
bodies with central pigment is a sure sign that segmentation is going on 
elsewhere. It has been found by the Italians that after the accumulation 
of a few pigment granules the organisms seek the internal organs, where 
segmentation takes place. The bodies are still small and contained within 
the red corpuscles. The pigment gathers in the center, as in the other types 
of segmentation, while the segments are very small and rarely more than 
twelve in number. During the paroxysm we may see large numbers of leu- 
cocytes containing pigment granules and clumps which are probably the 
remains of segmenting organisms. Flagellate bodies may be observed here 
as in the tertian and quartan fevers, but only when ovoid and crescentic 
pigmented bodies are present. They may be seen to develop from the round 



MALARIAL FEVER. 667 

bodies with central pigment. Careful studies concerning the morphological 
characteristics of the malarial parasite have shown that it belongs to the 
class of protozoa, and is possessed of a nucleus containing one or more 
nucleoli. At the time of sporullation this nucleus divides — according to 
some — directly, according to others by karyokinesis." 

Pathology. — In fatal malaria the following changes are found: — 

The spleen is enlarged; the capsule tense. Death has been reported 
from rupture of the spleen (Thayer). The pulp of the spleen contains large 
numbers of red blood-corpuscles in which the characteristic parasite is 
found. "The capillaries are usually filled with the plasmodia, while the 
splenic veins show relatively few, though they always contain large cells 
enclosing pigment or the remains of red corpuscles." 

The Liver. — Small areas of necrosis are described by Guarnieri : "Nu- 
merous liver cells are found containing clumps of haematin and altered 
red corpuscles, a condition similar to that found in pernicious anaemia. 
Bignami believes that this may explain the polycholia found in cases that 
died of pernicious malaria." 

Examination of the Blood. — A small drop of blood should be taken 
from the ear or from a finger tip. The usual aseptic precautions, such as 
carefully washing the finger with soap and water, followed by a washing 
with alcohol or ether, should be strictly carried out. Fresh blood must be 
examined soon after it has been withdrawn — no later than three or four 
hours. A film of blood can be preserved if the air is excluded by smearing 
vaseline around the edges of the cover glass. The amoeboid movements of 
the protozoa can be studied in this fresh blood. Blood for examination 
should be drawn about one hour before the expected paroxysm. The or- 
ganisms are much smaller after a paroxysm. 

"The tertian parasite completes its life in about forty-eight hours, or 
less, if there is any variation from this time. In the first twelve hours of 
their life the parasites appear as small, clear specks (hyaline bodies) in the 
red corpuscles, and if any pigment is to be seen it is as very small granules. 
If stained they appear pale blue. They are actively amoeboid, and remain 
so for about an hour after withdrawal. In the next twelve hours the para- 
sites have grown to about one-third the size of the corpuscle, are still 
amoeboid, show fine granules, and the corpuscle has become paler. In 
the next twelve hours the parasites have taken up about two-thirds of the 
cell, have become less amoeboid; the granules larger and moving. The 
parasites are now more irregular in shape, and the corpuscles larger and 
paler, the pigment granules standing out more markedly. In the next 
twelve hours all motion ceases, -the corpuscles become shells, the centers 
of which are occupied by the parasites, and spore formation and segmenta- 
tion begin. The organisms break up into fifteen or twenty round spores, 
at first contained inside the cell-wall of the red corpuscles, and then set free 



668 THE INFECTIOUS DISEASES. 

into the blood. It is at this time that the clinical paroxysm occurs. All 
hyaline bodies do not develop to the stage of spore formation, nor do all 
these spores — really the young hyaline bodies — which have been set free 
into the blood serum re-enter the red corpuscles, but the blood plasma 
itself destroys many of them. 

"Should we have under observation clinically a quotidian form of 
malaria, the red corpuscles would show the tertian parasite in but two stages 
of development, one group being approximately twenty-four hours older 
than the other ; of course, depending upon the hour at which the paroxysms 
occur. This is due to a double infection. It must not be forgotten, however, 
that we may have a triple quartan infection that produces daily paroxysms, 

"The quartan parasite grows in seventy-two hours. In the first twelve 
hours it is a very small, unpigmentecl, slightly amoeboid, hyaline body, be- 
coming in twelve hours more about the size of one-sixth to one-fifth that 
of the corpuscle, having taken on a few pigmented granules placed peri- 
pherally. In forty-eight hours it is one-half to two-thirds the size of the 
red corpuscle, round, as a rule, and possessing no amoeboid movement. In 
sixty hours from the paroxysm, it occupies nearly all of the corpuscle, 
which is neither enlarged nor paler than normal. In six hours more the 
pigment granules approach the center and are arranged like the spokes of 
a wheel, the first sign of segmentation. About three hours before the at- 
tack, segmentation has produced from six to ten oval or pear-shaped bodies 
or spores containing pigment in their centers. In multiple infections of 
this type we, of course, find the organisms in the blood in different stages of 
development. Flagellated bodies develop after the blood is removed from 
the body, and consist of a central cell with arms thrown out. These arms 
are freely movable. In examining a fresh specimen, we may see such a 
body keeping up a constant ciliary motion and causing a disturbance in the 
arrangement of the red cells in its immediate neighborhood. The flagellated 
body does not often appear in either of the foregoing types of the infection, 
but is more common in the sestivo-autumnal variety. The second group of 
parasites belongs to the class of malignant or aestivo-autumnal figures, and 
are divided into, first, the pigmented quotidian parasite ; second, the un- 
pigmented quotidian parasite ; and third, the malignant tertian. 

"The pigmented quotidian parasite completes its cycle in twenty-four 
hours. When seen in the blood-corpuscle, it appears as a small actively 
amoeboid, hyaline body, rapidly becoming pigmented and quiet, the pigment 
lodging in the periphery of the organism, after which it breaks up into 
spores. It has been pointed out that segmentation of this type does not take 
place in the peripheral blood, but occurs in the spleen and bone marrow. 
The pigmented organism occupies one-third of the corpuscle which is 
shrunken, if changed at all. After the infection has lasted for several days 
crescents appear. 



MALARIAL FEVER. 



669 



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670 THE INFECTIOUS DISEASES. 

"Crescents are always an evidence of cestivo-autumnal fever, and never 
occur in the quartan or tertian type. They are from eight to ten micro- 
millimeters in length and from two to three micromiilimeters in breadth, 
are half-moon shaped when typical, but vary greatly, oftentimes appear- 
ing almost straight. They contain pigment sometimes scattered, but 
oftener found clumped in the center, and usually without motion. With 
a good light and an accurate adjustment the shell of the red blood-cor- 
puscle can be seen extending from the poles of the crescent, showing that 
this parasite is distinctly an intracellular formation. Crescents are dis- 
tinctly an evidence that the infection has lasted a number of days, — five or 
six — and they will not be found in any specimen before that time. The 
unpigmented quotidian parasite shows not many variations from the fore- 
going type, except that it is free from the pigment, though the crescents 
formed from this variety may show pigmentation. The malignant tertian 
parasite is pigmented and, in fact, much like the pigmented quotidian. It 
grows to segmentation once in forty-eight hours, and is amoeboid in the ad- 
vanced stage; the pigment is active and the entire organism is larger. Prob- 
ably no better idea can be given concisely of the different characteristics of 
these parasites than by reproducing the table of Mannaberg." (See p. 669). 

Symptoms. — In very young children there may be convulsions, restless- 
ness, cold extremities, and yawning. The pulse is full and rapid. The tem- 
perature may reach as high as 105° F., or even higher. After this febrile 
stage the body is cohered with a profuse perspiration, ending in sleep from 
exhaustion. Diarrhoea is ocasionally met with in this condition, and is prob- 
ably the result of secondary infection. Bronchitis is occasionally seen. The 
paroxysm of fever occurs when the protozoa matures and begins to divide. 
This process repeats itself about every twenty-four hours in the tertian type 
of intermittent fever most frequently seen in this country. If children 
are carefully observed, then the onset of a paroxysm is frequently seen 
by a severe cyanosis affecting the nails. This would correspond to the 
chill seen in the older children. Slight albuminuria or hematuria fre- 
quently accompanies malaria. There is no disease that can be mistaken 
for the tertian type of malaria when it is remembered that there is a sick 
day with fever, etc., and an alternating apparently healthy day. 

An enlarged spleen is usually present. 

Diagnosis. — This can be most positively made by an examination of 
the blood. So many symptoms present in malaria, such as lassitude, pains 
in the bones, headache and fever, simulate other diseases, that only the posi- 
tive finding of Laveran's protozoa in the blood will complete the diagnosis. 

Differential Diagnosis. — If there is a doubt as to the differential diag- 
nosis between tuberculosis and malaria, the specific effect of .a few doses of 
quinine will easily show the presence or absence of malaria. The blood test 
is, however, conclusive. 



MALARIAL FEVER. g 71 

A boy, 6 years old, was brought to me at the children's service of the German 
Poliklinik with a history of headache, fever, and pain in the bones. The boy ap- 
peared rather icteric. His mother said that he had lost weight during the last 
two weeks. He perspired freely, had a good day and a bad day. The fever appeared 
in the afternoon. The examination showed a well-nourished boy, lungs normal, a 
slight haemic murmur at the apex of the heart which was also heard in the vessels 
at the neck. The spleen was palpable and slightly enlarged. The appetite was poor, 
the bowels moved sluggishly. The child was restless at night. The examination 
of the blood showed the presence of the ordinary tertian parasite. Quinine in 3- 
grain doses was given every four hours, and 6 grains were given three hours before 
the expected attack, which in this condition was between 1 and 2 o'clock in the 
afternoon. Fifteen drops of cascara sagrada were administered before breakfast 
of each day. The treatment was continued for ten days. The boy then complained 
of buzzing in the ears, evidently due to cinchonism. Quinine was given every second 
day and Fowler's solution in 3-drop doses was administered on alternate days. 
Strengthening food was given and the child made a complete recovery. Quinine was 
given once every three days after the first month. The child took an ocean 
voyage and was perfectly well in two months. Iron was then given for several 
months as a tonic and the treatment discontinued. 

Prognosis. — This is usually good. If malaria is neglected severe an- 
aemia follows, and if pernicious malaria results it may end in death. In 
this country the specific effect of quinine and the change of climate usually 
gives successful results. 

Treatment. — A patient suffering with malaria should, if possible, be 
removed to a different climate. A change from the city to the country, 
or vice versa, is very beneficial. Xext in importance to change of air is 
the specific effect of quinine. Five grains of quinine (0.3) can be given 
to a child 3 years old. The hydrochlorate of quinine is the most effective. 
Owing to its disagreeable taste it can be given in tablet form, after which 
a mouthful of coffee or chocolate can be given. When quinine is refused 
by mouth, then a 10-grain dose in the form of a suppository can be given 
three times a day, per rectum. The best time for administering quinine is 
about three hours before the expected attack. The bisulphate of quinine 
is a soluble and convenient form to use. It is very important to keep the 
bowels open and the kidneys active. Fifteen to 30 drops of fluid extract 
of cascara sagrada can "be given in a palatable menstruum every morning, 
so that the action of the bowel is assisted. In true malaria, I have found 
especial benefit in administering whisky well diluted with water, or given 
in milk. Apart from its nutritive properties, it certainly has decided anti- 
septic properties. If -malaria persists in spite of continued treatment, then 
arsenious acid in doses of 1 / 100 or y i50 grain, can be administered three 
times a day. Fowler's solution, in doses of 1 to 5 drops, should not be 
forgotten. Jacobi recommends ergot in doses of 20 to 50 drops every day 
for weeks. When it is not well borne he combines it with quinine or arsenic. 
I have never been able to see the slightest benefit from the use of ergot, 
although I have tried it in many cases. I believe Jacobi's results were good 
when he combined the ergot with the quinine because the quinine was given. 



CHAPTER XV. 
SYPHILIS. 

This is a specific disease most probably caused by the invasion of a 
micro-organism called Spirochceta pallida. The disease in infancy is the 
same as that in -adults. There are two forms of the disease: — 

1. Inherited syphilis. 

2. Acquired syphilis. 

Etiology. — The most frequent modes of infection are:-^ 

By nursing from the breast of a syphilitic wet-nurse. 

Eating from the dishes of syphilitic patients. 

Unclean surgical instruments; for example, when an infant is vac- 
cinated, or during the operation of circumcision. 

The Transmission of Syphilis in Utero. — An infant in utero may be 
infected directly through the circulation in the placenta. If the mother 
acquires syphilis during the ninth month of her pregnancy, the same will 
not infect her child nor modify its development. A healthy infant in 
utero can be infected by passing through a syphilitic genital tract of its 
mother during labor. 

When the ovum is infected with syphilis, which frequently happens 
-at the time of conception, it may terminate in the death of the foetus, re- 
sulting in an abortion or in the birth of a still-born child. If the child 
lives it may suffer with cachexia, and a few weeks later present the char- 
acteristic skin-lesions. The father can infect the mother for three or, at 
the most, five years after his chancre. The father may infect the foetus as 
late as twenty years after his chancre, when for years he has presented no 
signs of syphilis. The mother may have a series of syphilitic pregnancies 
resulting in miscarriages or in syphilitic infants, without at any time 
herself presenting any syphilitic manifestations. In the same couple the 
severity of the infection transmitted to the foetus tends to decrease with 
succeeding pregnancies. Thus it is the rule for the mother to have at 
first several abortions, then a child born dead, and finally a living child 
showing the evidences of inherited syphilis. Children born later usually 
suffer less severely, but this "law of decreases" (Diday) is not without nu- 
merous exceptions; sometimes the third or fourth child suffers more than 
the second. In other families children of one sex suffer more than those 
of the opposite sex. In twin pregnancies one may be affected while the 
other apparently escapes. The apparent escape of the mother of syphilitic 
infants by a syphilitic father has been accounted for on the supposition 
(672) 



SYPHILIS. 673 

that she undergoes a mitigated infection derived from the foetus. Coutts 1 
has pointed out the theory that she absorbs from the foetus a syphilitic anti- 
toxin; this would account not only for her apparent immunity, but also for 
the gradual decrease in the severity of the disease in later pregnancies. If 
the mother be infected but not the father, death of the foetus is the most 
likely result. If the child is born alive it will probably suffer from in- 
herited syphilis. If both parents have suffered from manifest syphilis, the 
chance of abortion or still-birth is greater. 

Colles's Law. — In 1837 Colles wrote that "A new-born child affected 
with inherited syphilis, even though it may have specific lesions in the 
mouth, never causes infection of the breast which it sucks if it be the mother 
who nurses it, although continuing capable of infecting a strange nurse." 
The substantial truth of this dictum has not been seriously questioned, 
though various explanations have been offered. 

Butyric-acid Test for Syphilis. 2 — This test depends on the precipitation 
of globulin, either in the blood-serum or in the cerebrospinal fluid. The 
Noguchi test consists of the following: — 

From one-tenth to two-tenths c.c. of cerebrospinal fluid, which is 
absolutely free from blood, is mixed with one-half c.c. of a 10 per cent, 
solution of butyric acid in normal saline, and boiled. Then one-tenth c.c. 
of 4 per cent, sodium hydroxid solution is quickly added, and the whole 
boiled for a few seconds. A granular or floccular precipitate means a 
positive reaction. The precipitate appearing within a few minutes indicates 
a large increase in globulin, while a weaker reaction may not appear for 
an hour or two, two hours being the time limit. 

If this test gives the spinal fluid only a slight opalescence or tur- 
bidity and no granular precipitate, then we can consider the fluid normal 
after the usual time limit has been reached. 

With the cerebrospinal fluid, a positive reaction occurs in any case 
of syphilitic or parasyphilitic affection; also in all acute or chronic in- 
flammations of the meninges, whether due to the meningococcus, the tubercle 
bacillus, the pneumococcus, the streptococcus, or the influenza bacillus. In 
the early stage of polionryelitis the reaction is also positive. In acute luetic 
meningitis the presence of Treponema pallidum in the cerebrospinal fluid 
will serve to exclude other forms of meningitis. 

In hydrocephalus, the cerebrospinal fluid gives a positive butyric-acid 
test in cases which are of syphilitic origin. In pneumonia, with an in- 
creased amount of cerebrospinal fluid without inflammation of the meninges, 
the fluid does not give a positive butyric-acid test. 



1 "Some Aspects of Infantile Syphilis." Hunterian Lectures, London, 1897. 
2 1 am indebted to Dr. Hideyo Noguchi for assistance in the preparation of 
this article. 

43 



674 THE INFECTIOUS DISEASES. 

The test is most valuable in differentiating between inflammatory and 
non-inflammatory conditions of the meninges in children. The blood-serum 
test is too complicated to be tried outside of a highly equipped laboratory. 

Pathological Anatomy. — In obscure inflammatory lesions involving the 
meninges or spinal cord, it is necessary to submit the spinal fluid as well 
as the blood to the Noguchi or the Wassermann test. While the Noguchi 
test is very sensitive, one should not fail to utilize the Wassermann to 
confirm the presence or absence of a positive reaction. In acquired syphilis 
changes are the same in the child as in the adult. 




Fig. 218. — Spirochseta pallida. Macerated skin of foetus. 
(Courtesy of the Rockefeller Institute, New York.) 

In hereditary syphilis there are certain constant changes present in 
the bones. These changes are confined to the shafts of the long bones and 
to the cranial bones. 

The pathological changes are not confined to the epiphyses, but the 
diaphyses are also swollen. The ends of the bones are swollen. The inner 
portion of the periosteum shows swelling and hypersemia. 

The circulatory apparatus shows thickening of the arterial walls as 
well as of the veins. Owing to this degeneration there is a tendency to 
bleeding. (See clinical case described in this chapter.) 

Catarrhal manifestations showing implication of the respiratory tract, 



SYPHILIS. 675 

and also the gastro -intestinal tract, can be noted. The liver, spleen, and 
pancreas are enlarged. 

The lymph glands of the entire body are enlarged. 

Symptoms. — When catarrh is troublesome in children and not amen- 
able to ordinary treatment, syphilis should be suspected. It is surprising 
to find the frequency with which nasal and nasopharyngeal catarrh is asso- 
ciated with syphilis. I have not yet had occasion to regret asking a direct 
question of a parent in whom I suspected syphilis, if such parent is told 
that we must know his previous history, for the benefit of his child. 

Gastro-intestinal Tract. — The gastro-intestinal tract is the one that 
will frequently show the manifestations of syphilis. An infant will not 
appear to thrive nor will it digest, in spite of the most careful dietetic meas- 
ures. Syphilitic lesions of the liver, pancreas, stomach, and intestine are 
simply all part of the infection. Anti-luetic treatment will frequently do 
more good in a few days or weeks than months of rigid diet. Thus it is 
apparent that in order to do good in this disease we must seek to remove 
the cause. 

When a -persistent diarrhoea will not respond to the ordinary treat- 
ment of careful diet and medication, then suspect syphilis. When diar- 
rhoea such as a mucus-colitis persists without fever after careful dieting, 
then syphilis may be suspected. 

The following case will illustrate congenital syphilis : — 

An infant about one iccck old was seen by me. It was the fourth child of 
apparently healthy parents. Three children had previously died, and this fourth 
child was born at full term. The mother noticed that the child cried incessantly and 
was very restless. The child had had sniffles since birth. It was breast-fed and 
appeared to suffer with colic and hunger. The stools -were grass-green and con- 
tained mucus and curds. The palms and soles had a pemphigus. The skin had a 
yellowish tinge. The nose was excoriated from the discharge. The anus had deep 
cracks — the so-called rhagades. Around the mouth were also rhagades. The 
spleen was enlarged and palpable. The lymph glands were not enlarged. The chill 
did not seem to thrive. The finger nails showed distinct evidences of the disease. 
The bones of the fingers and toes showed the presence of dactylitis syphilitica. The 
diagnosis of congenital syphilis was made. The mother had plenty of milk, but 
was compelled to wean the child owing to a typhoidal condition to which she sue* 
cumbed. The infant was bottle-fed, and when about five weeks old developed a large 
abscess on the forearm which was incised under an anaesthetic by Dr. Geo. F. Shrady. 
One week later a series of metastatic abscesses formed over the abdomen and on 
the back. The child died from inanition and general sepsis when about nine weeks 
old. 

Hcemorrhages from the nose and mouth, and bloody stools due to ulcer- 
ation of the intestinal tract are frequently reported. 

Uracek has reported hemorrhages in the different internal organs 
caused by syphilis in the infant. Umbilical haemorrhages are sometimes 
due to syphilis, according to Eotch. 



576 THE INFECTIOUS DISEASES. 

The following case will illustrate bleeding in the new-born : — 
An infant suffered with a severe form of marasmus and athrepsia. It did not 
develop. Examination of the mucous membrane of its mouth, gums, and fauces 
showed distinct patches. The child was attended by Dr. Honor, of New York City, 
who referred the case to Dr. W. Freudenthal for diagnosis. The case was also seen 
by me and I concurred in the opinion expressed, that the patches were non- 
diphtheritic and were most likely due to syphilis. Several days later Dr. Freudenthal 
and myself were again called to see this child owing to an extensive nasal haemor- 
rhage. In spite of the most active local treatment, the use of haemostatics, such as 
adrenalin, and the use of styptics internally and externally, the infant died from 
exhaustion. The attending physician, Dr. Honor^ subsequently stated that he had 
found distinct evidence of syphilis. 

Skin Lesions. — The skin lesions develop soon after those of the mu- 
cous membrane. The eruption consists of small, round, pink macules, which 
disappear on pressure. While the eruption may be on the abdomen and 
lower limbs, it not infrequently is found all over the body. At times the 
eruption resembles an erythema and is copper-colored. Sometimes the 
eruption is papular; it is not infrequent to find condylomata around the 
mouth or anus. These condylomata are very contagious. -Pustules are 
frequently seen as early as two months. This eruption can be differentiated 
from eczema by the characteristic absence of itching that always accom- 
panies eczema. Furuncles are usually found in poorly nourished children. 
The infant usually has the appearance of a shriveled old man. 

The Teeth. — The teeth in congenital syphilis, instead of appearing at 
the sixth or seventh month, may not appear until the fourteenth or fif- 
teenth month, and even later. These teeth are usually carious. 

Congenital Syphilitic or Hutchinson's Teeth. — This variety of dental 
abnormality is important, because, as Hutchinson says, "It is, if taken 
alone, by far the most valuable of the signs by which we recognize in 
adolescence the effect of inherited syphilis." The characteristics of these 
teeth are not sufficiently known, and abnormal and peculiar teeth of other 
kinds are often erroneously regarded as proofs of congenital syphilis. The. 
main points about "Hutchinson's teeth" are as follows : — 

1. It is always the permanent teeth which are affected. The tem- 
porary teeth in syphilitic infants often decay early, but they present no 
special peculiarities of form. 

2. The characteristic peculiarities which distinguish these central 
incisors are as follows : They are dwarfed, being too short and too narrow ; 
and sometimes the portion of the upper jaw from which they grow is also 
arrested in growth. They often stand somewhat apart and slope toward 
one another. They are unusually rounded on section; they are "pegged" 
and they are notched. The notch is usually shallow and the dentine is 
exposed at the bottom of it. It is formed by the breaking away of the 
imperfectly developed central portion of the edge. The teeth are generally 



SYPHILIS. 



677 



not of a good color, and they are abnormally soft, so that by the time the 
patient is 20 they may be ground down like those of an old man. 

The first molars are next in diagnostic importance to the upper cen- 
tral incisors. When characteristic they are spoken of as "dome-topped." 
Their sides slope toward the center, over which the enamel is defective. As 




Fig. 219. — Syphilis. Child 14 years old. A productive periostitis enclosing the 
shafts of the long bones. Absolutely characteristic of syphilis. 



might be expected, syphilitic teeth not infrequently present the character- 
istics of mercurial teeth in addition to their own peculiarities. 

Diagnosis and Differential Diagnosis. 1 — The clinical history will be the 
guide in congenital syphilis. The history of previous abortions and still- 
born children will aid in establishing a diagnosis. 

The cachectic skin, the wrinkled mouth, and rhagades at both mouth 
and anus will materially aid in establishing a diagnosis. 



See "Blood in Syphilis," page 685. 



678 THE INFECTIOUS DISEASES. 

Table No. 68. — Differential Points Between Syphilis and Tuberculosis. 

( Morrow. ) 

SYPHILIS. TUBERCULOSIS. 

Exhibits a marked predilection for the Is almost exclusively situated in the 

long bones; its habitual localization is epiphysis, rarely affecting the shaft. 
in the diaphysis and almost always at 
its terminal extremity. 

There is a marked enlargement of the The tumefaction is due less to increase 

bone by more or less voluminous osseous in the size of the bone than to cedema- 

tumors or hyperostoses, with little or no tous infiltration of the soft structures, 
involvement of the soft parts. 

There is little tendency to suppuration The pyogenic tendency is marked, 
and necrosis. 

Osteocopic pains with tendency to The pain is dull and heavy, not aggra- 
nocturnal exacerbation are pronounced vated at night; sometimes there is en- 
features, tire absence of acute painful symptoms. 

The osseous lesions rarely react upon The osseous lesions often determine a 

the general system. marked impairment of the general" 

health, grave complications, hectic fever, 
cachexia, etc. 

In dactylitis there is little involve- In dactylitis the swelling is due more 

ment of the soft parts, the swelling to an cedematous infiltrated condition of 

being caused by the enlargement in the the soft tissues than to enlargement of 

size of the bone. the bone. Breaking-down of the tissues 

and ulceration are more apt to ensue. 

At times pseudo-paralysis will be present; sometimes coryza, hoarse- 
ness, inflamed eyes, and persistently running ears. 

The Wassermann Reaction. — In suspicious cases the blood should be 
examined to see if we get a positive Wassermann reaction. • 

Luetin Test. — This reaction devised by Noguchi is apparently specific 
for syphilis. It is useful after the spirochete can no longer be demonstrated, 
and when the Treponema pallidum still survives in the body. As a rule 90 
per cent, of hereditary syphilis gives a positive reaction. Under 1 year 
the reaction is indistinct; from 2 to 6 years it gradually increases. Late 
cases are almost always positive. Exceptions are few. Cases with a strong 
Wassermann reaction and clinically unfavorable cases give a negative 
reaction. 

An emulsion of pure culture of Treponema pallidum is prepared and 
0.057 cubic centimeter is injected under the skin by means of a fine needle. 
If a red, indurated papule forms after twenty-eight to forty-eight hours, 
surrounded by a diffuse zone of redness, the reaction is positive. 

This redness increases for three to four days, then disappears within 
a week. A slight rise of temperature may accompany this reaction. 

"The diagnosis between syphilis and rachitic bone lesions may become 
of great importance. Epiphyseal swellings occurring under six months are 
apt to be syphilitic. In syphilis the epiphyseal swelling may be unilateral, 
but it is always symmetric in rachitis. In doubtful cases the swelling must 



SYPHILIS. 



679 





Fig. 220. 



Fig. 221. 





!22. Fig. 223. 

Figs. 220-223. — Syphilitic Teeth. Various types of hereditary syphilitic 
teeth, as described by Hutchinson; also parenchymatous keratitis. Note 
that the upper central incisors show the positive evidence of syphilis. 
(Uourtesy oi Dr. Hugo Neumann.) 



680 



THE INFECTIOUS DISEASES. 



'be subjected to specific treatment. Rickets and syphilis may coexist in the 
same case. There is almost invariably enlargement at the costochondral 
articulations in all cases of rickets, which is absent in syphilis." 

Prognosis. — This depends upon the condition of the child at the time 
treatment is commenced. Such children have very little or no vitality. 

Hereditary syphilis can be transmitted to healthy children, so that 
the precaution of strict isolation should be remembered. 

Treatment. — -The therapy of syphilis has undergone a radical change 
since the introduction of salvarsan. Through the courtesy of Prof. Ehrlich, 




Fig. 224. — Congenital Syphilis Before Injection of Salvarsan. (Original.) 

I received a liberal supply of salvarsan, also known as dioxydiamidoarseno- 
benzol or "606." 

No case should be injected until a positive Wassermann reaction has 
been obtained. The choice of the technique of the injection is one of 
preference, although the intravenous method seems most popular because 
of better results. The following doses are recommended : For an infant 1 
year old, an injection of 0.06 gramme, to be followed in one week by an 
injection of 0.1 gramme (intravenous method) if no severe systemic reaction 
follows the first injection. For a child 5 years old an injection of 0.1 
gramme, followed one week later by an injection of 0.2 gramme. Complica- 
tions must be guarded against. When we recall that one-third of salvarsan 
consists of arsenic, then the toxicity of the same is well brought out. By the 
intravenous method we diffuse the efficiency of this drug into the circula- 
tion and prevent the cumulative effect which usually follows the intramus- 
cular injection. 



SYPHILIS. 



681 



In one of my cases 1 severe necrosis of the tissues in the gluteal region 
was followed by a series of deep abscesses. In addition thereto, a multiple 
neuritis developed which involved the lower limbs and persisted until five 
months after the injection was given. The syphilitic ulcerations and 
condylomata around the vagina and anus improved after three or four days 
and practically disappeared. This child was 18 months old and received 
0.3 of an alkaline solution of salvarsan injected into the gluteal region. 

B. L., six years old, a former patient of Dr. Tunick, was admitted to the 
babies' ward of the Sydenham Hospital. The mother had an innocent infection. 




Fig. 225. — Appearance of Lesions One Week After Injection of 
Salvarsan. (Original.) 



The child showed distinct evidences of syphilis. Two years previous a gumma of 
the left testicle existed, and said testicle was removed. At time of admission he 
had very marked superficial veins, periostitis, and gumma of the left knee-joint. 
The Wassermann reaction and the Noguchi reaction were positive. All serological 
examinations were made by Dr. D. M. Kaplan. 

One injection of 0.3 salvarsan, in a neutral solution, was given, with aseptic 
precautions in the left buttock. No local reaction followed. The child made a 
brilliant recovery. The swelling in joint subsided after three days. The boy walked 
in one week and was discharged two weeks after admission. 

Local Treatment. — The safest method of administering mercury is 
in the form of bichloride baths. These baths can be given in a wooden 



1 Reported in the Journal of American Medical Association, February 11, 1911. 



682 THE INFECTIOUS DISEASES. 

tub, in which enough water is drawn to cover the child's body. From 5 
to 10 grains of bichloride can be added to this tub of water. Infants up to 
1 year can be bathed from ten to twenty minutes every day. 

The presence of eczematous or other skin eruptions would not contra- 
indicate giving these baths. 

The inunction of chemically pure mercurial ointment well rubbed into 
the axillae/ knee-joints, or the thighs will materially aid in bringing this 
drug into the system. 

For the relief of syphilitic warts nothing is better than: — 

I£ Bichloride 10 parts 

Alcohol 100 parts 

Apply with absorbent cotton several times a day. 

Internal Treatment. — Internally calomel and bichloride or the tannate 
of mercury can be given in suitable doses. It is advisable to give the child 
from 1 to 5 grains of iodide of sodium, according to age, to alternate with 
the mercurial treatment. 

Care should be taken that stomatitis is not developed in nurslings. If, 
however, stomatitis has developed, then active and persistent treatment with 
chlorate of potash solution, locally, will be found effectual. 

It is self-understood that hygienic treatment in addition to careful 
diet is just as important as the specific drug treatment. 

Feeding. — A diet of milk, eggs, cereals, fish, and fruit should form the 
basis of nutrition. The reader is referred to the articles on "Marasmus" 
and "Kickets" as a guide to the method of feeding necessary to reconstruct 
a weakened child. 



PART VIII. 

DISEASES OF THE BLOOD, GLANDS OR LYMPH NODES, 
AND DUCTLESS GLANDS. 



CHAPTEE I. 
INTRODUCTORY. 

The Blood. 1 



The red corpuscles (also known as the erythrocytes). The red cor- 
puscles of the blood are more numerous at birth than in later life. Hayem 
and Helot found that when the umbilical cord was not tied until its pulsa- 
tions ceased, a greater number of red corpuscles were found than in cases 
where immediate ligation was performed. Leder and Hutchinson, com- 
paring the new infant's blood with that of its mother, found that the blood 
of the infant contained a larger number of red corpuscles. The following 
table will show the difference in blood count by various writers : — 

Table No. 69. 

Hayem averaged 5,360,000 

Sorensen " 5,665,000 

Otto " 6,165,000 

Bouchat and Dubrisay " 4,300,000 

Schiff (one ease) , " 6,658,000 

Gundobin " 6,700,000 

Elder and Hutchinson " 5,346,560 

Schwinger greatest at birth. 

The difference varies between 350,000 and 500,000 per cubic milli- 
meter. Gundobin believed that the concentration of the blood was caused 
by loss of water through the lungs. Schiff found the same condition; he 
also states that the number of corpuscles decreases when the child is put to 
the breast. The number of red corpuscles begins to fall after the second 
day. 

In one case Schiff studied the number in the morning and evening 
during the first fifteen days of life; he found the number declined irregu- 
larly. The first day's count was 7,628,000 ; the last day's count was 4,565,- 
600; the average for the fifteen days was 5,828,465. 

According to Schwinger and Gundobin, there is a decrease in the 
number during the first year ; after this there is an increase up to the eighth 

1 1 am indebted to Stengel and White, Archives of Pediatrics, April, 1901, for 
many valuable points in the preparation of this article. 

(683) 



684 DISEASES OF THE BLOOD. 

or twelfth year, when the number becomes approximately that of adult life. 
Sex makes no difference in the count of the red corpuscles in infancy. 

Size. — The red corpuscles vary greatly in size at birth and during the 
first few days of life. Hayem found variations between 3.25 ^ and 10.25 u 
and Loos found the size varying from 3.3 ^ to 10.3 M . Gundobin claims 
that the haemoglobin is more firmly attached to the cell stroma in the new- 
born infant. He also calls attention to the great number of small-sized 
corpuscles. 

The Hcemoglobin. — According to Morse, Elder, Hutchinson, Taylor, 
and Eotch, haemoglobin is increased at birth, but the percentnge declines 
rapidly during the first few days of life. According to Eieder, there is an 
excess of 25 to 30 per cent, at birth compared with infants after feeding 
has begun. 

Specific Gravity. — This varies just like the haemoglobin. At birth the 
specific gravity is high. 

Monti found the specific gravity at birth 1060 

Rotch found the specific gravity at birth . . . 1065 

Hoch & Schlesinger found the specific gravity at birth .... 1066 

Moelle found the specific gravity at birth 1060 

The specific gravity may not vary for weeks or months in healthy 
children. 

The White Blood Corpuscles (Leucocytes). — Leucocytes are found in 
greater number at birth than in later life. This excess in number lias fre- 
quently been spoken of as a normal condition. It is also called the physio- 
logical .leucocytosis of the new-bom, 

Table No. 70. 
Physiological Leucocytosis. . Pathological Leucocytosis. 

1. Leucocytosis of the newborn. 1. Inflammatory and infectious leuco- 

cytosis. 

2. Digestion leucocytosis. 2. Leucocytosis of malignant disease. 

3. Leucocytosis due to thermal and 3. Toxic leucocytosis. 
mechanical influences. 

4. Thermal leucocytosis. 4. Experimental leucocytosis. 

Pathological Conditions. — In disease the first change noticed will be 
a reduction in the percentage of haemoglobin, and also in the number of 
erythrocytes. There are smaller forms of red corpuscles called microcytes. 

Nucleated Bed Corpuscles (Erythroblasts) . — These cells have been 
found in primary and secondary anaemias by many observers. They have 
also been found very abundant in syphilis, rachitis, tuberculosis, pseudo- 
leukaemia, and osteomyelitis. 

Leucocytosis. — In leucocytosis an increase in the number of leucocytes 
is found in the blood of anaemic children. It is also found in toxic and 



THE BLOOD. 685 

inflammatory conditions. Myelocytes are more frequently found in the 
blood of children than in adults. Cabot and Engel ascribe a bad prog- 
nostic significance in pneumonias and diphtherias to their presence. 

Acute colitis causes concentration of blood, with considerable leu- 
cocytosis. 

Inflammatory leucocytosis is classified, according to Cabot, as follows : — 

1. Infection mild; resistance good; small leucocytosis. 

2. Infection less; mild; resistance good; moderate leucocytosis. 

3. Infection severe; resistance good; very moderate leucocytosis. 

4. Infection severe; resistance poor; no leucocytosis. 

Table No. 71. 

Red Hood-corpuscles. Leucocytes. 

Birth 5,900,000 21,000 

Seventh day 5,000,000 15,000 

First year 5,000,000 10,000 

Sixth year 5,000,000 7,500 

(Coles.) 
Proportion of Leucocytes in Adults and Infants. 

Adults. Infants. 

Small uninucleated 24 to 30 per cent. 50 to 75 per cent. 

Large uninucleated 3 to 6 per cent. 6 to 14 per cent. 

Multinucleated or neutrophile ... 60 to 75 per cent. 28 to 40 per cent. 

Eosinophile cells 1 to 2 per cent. ^ to 10 per cent. 

In studying a series of blood counts in babies, Warfield found the 
youuger the infant the higher the leucocyte count. Gundobin and Carstaujen 
found that the increase is due chiefly to an excessive gain in the polynuclear 
neutrophiles. 

Infectious Diseases. — In diphtheria, scarlatina, pneumonia, and ery- 
sipelas the polymorphonuclear cells are greatly increased (Weiss and Gun- 
dobin). Gundobin found an increase in the number of leucocytes before the 
eruption in scarlet fever, measles, and erysipelas. In typhoid fever the 
number of leucoc}'tes is decreased; there may be also a decrease in the 
number of red corpuscles and in the percentage of haemoglobin. The num- 
ber of leucocytes is relatively increased. The polymorphonuclear cells are 
decreased 

Pneumonia. — Leucocytosis is usually present in this disease. When it 
is absent the prognosis is grave. 

Syphilis. — In hereditary syphilis an anaemia is found with a decrease 
of the red corpuscles and great degenerative changes (poikilocytosis). In 
syphilis we lind microcytes and macrocytes and nucleated erythrocytes. 
Myelocytes are also found. Eosinophils are also met with in this condition. 

Bronchitis. — A slight leucocytosis with especial increase of the lympho- 
cytes or mononuclear cells. 



G86 DISEASES OF THE BLOOD. 

G astro-intestinal Disease. — The condition of the blood varies accord- 
ing to the extent of the process, the duration, and the existence or non- 
existence of diarrhoea and vomiting. Profuse diarrhoea and vomiting may 
for a time thicken the blood by loss of water. Weiss shows an increase of 
the leucocytes and transitional leucocytes. 

Rachitis. — There is usually a reduction in the number of red corpuscles, 
a decrease in the percentage of haemoglobin, and an accompanying leuco- 
cytosis according to von Jaksch. 

Skin Diseases. — There is an increase in the number of eosinophiles. 
The cause of the same is unknown. 

Nervous Diseases. — In the functional disorders of childhood the blood 
findings are those of a moderate anaemia. Burr has found that the blood 
in chorea is not as a rule anaemic. In my own examinations (Fischer) the 
opposite result has been found, and I believe that in prolonged chorea a 
distinct leucocytosis can be found. 

Blood Eeaction of Pus. — The glycogenic reaction of the blood has fre- 
quently been described in literature. The first complete paper on this 
subject was published by Dr. M. Goldberger and Dr. Siegfried Weiss. 1 This 
diagnostic aid is of value when a questionable diagnosis exists. 

When an abscess exists, especially if it is localized, there is invariably a 
marked leucocytosis, even in limited suppurative foci. In the subcutaneous 
or interstitial connective tissue there is always a high leucocytosis. Ewing 
found marked leucocytosis in the active stages of otitis and all suppurative 
processes which subsided rapidly after the operation. There was one 
exception in abscess of the liver with mucopurulent exudate. 

Iodine Eeaction (lodophilia). — This reaction consists in slight or 
intense reddish-brown granules' and a diffuse brown coloring of the entire 
protoplasm. The protoplasm of the polynuclear neutrophile leucocytes 
shows a marked affinity for iodine. This intracellular iodine reaction is 
present in purulent conditions and persists as long as suppuration is present. 
It has an important diagnostic bearing when abscesses are deep seated. 
Cabot and Locke 2 obtained uniformly positive reactions in septicemia, 
pneumonia, empyema, and suppurative appendicitis; in serous pleural 
eifusions and in catarrhal appendicitis the test was negative. In about 
one-half of the cases of enteric fever examined by these writers the test was 
positive, usually, only in those complicated by haemorrhage, perforation, 
furunculosis, or lung lesions. These studies have been more recently sub- 
stantiated by Gulland. 3 

The following table, prepared by Casper Sharpless, will assist in the 
differentiation of the blood : — ■ 



1 Wiener klinische Wochenschrift, No. 25, 1897. 

2 Journal of Medical Research, 1902, vol. vii. 
'British Medical Journal, 1904, vol. i. 



PLATE XXXI 
Iodophilia. Pus Reaction of Blood. 




Coverglass Specimen of Blood in a Case of Suppurative Appendicitis. 
a, Polynuclear leucocytes; b, polynuclear leucocytes containing many irreg- 
ular granules of glycogen; c, extra-cellular iodine-stained masses, giving the 
reaction of glveogen. 




a, Pus corpuscles without iodine reaction ; b. pus corpuscles, iodine reaction. 

(Original, i 



THE BLOOD. 
Table No. 72. 



687 



Disease. 


Leucocytosls. 


Lymphocytes. 


Neutrophils. 


Red Cells. 


Haemoglobin. 


Typhoid Fever 


Absent 


Relatively 
increased 


Decreased 


Decreased 


Proportionately 
decreased 


Typhoid with 
complications 


Present 




Increased 


Decreased 


Proportionately 
decreased 


Scarlet fever . 


Present 


Decreased 


Increased 


Decreased 


Proportionately 
decreased 


Measles. . • • 


Absent 






No change 


No change 


Small pox . . 


Marked on 
third day 




Increased 


Much de- 
creased 


Proportionately 
decreased 


Erysipelas . 


Marked 




Increased 


Decreased 


Proportionately 
decreased 


Diphtheria . . 


Marked 


Rarely 
increased 


Increased 


Slight de- 
crease 


Proportionately 
decreased 


Influenza. . . 


No change 






No change 


No change 


Typhus fever 


No change 






No change 


No change 


Follicular 
tonsillitis 


Moderate 






No change 




Acute rheu- 
matism . 


Moderate 




Increased 


Markedly 
decreased 


Markedly 
decreased 


Septicaemia . • 


Marked 




Increased 


Markedly 
decreased 


Proportionately 
decreased 


Abscess. . . . 


Marked 




Increased 


Decreased 


Proportionately 
decreased 


Meningitis . 


Marked 




Increased 


Slightly 
decreased 


Proportionately 
decreased 


Peritonitis 


Marked 




Increased 


Slightly 
decreased 


Proportionately 
decreased 


Pericarditis . 


Marked 




Increased 


Slightly 
decreased 


Proportionately 
decreased 


Pleurisy 


Marked 




Increased 


Slightly 
decreased 


Proportionately 
decreased 


Malaria . . 


Absent 


Relatively 
increased 


Decreased 


Decreased 


Proportionately 
decreased 


Pneumonia 1 . 
Appendicitis 


Marked 
Marked 


Decreased 


Increased 


Decreased 


Proportionately 
decreased 



In pneumonia there is a decrease of the eosinophiles and in scarlet fever an increase. 

Table No. 73. 



Reaction Present in 
Empyema. 

Suppurative appendicitis. 
Enteric fever when complicated by fu- 

runculosis or pulmonary lesions. 
Gonorrheal arthritis. 
Influenza. 

Cerebro-spinal meningitis. 
Sepsis ( septicemia ) . 



Reaction Absent in 
Serous pleural effusion. 
Catarrhal appendicitis. 
Enteric, fever when uncomplicated. 

Rheumatic arthritis. 
Pure tuberculous abscesses. 



688 DISEASES OF THE BLOOD. 

The persistence of this reaction after the incision of a pus cavity sug- 
gests, frequently, imperfect drainage.. 

The staining solution as advised by Goldberger and Weiss 1 is as 
follows : — 

Iodin 1 

Potassium iodid 3 

Distilled water 100 

Mix and add sufficient gum arabic (about 50 parts) to make a 
syrupy mixture. 

With a camer's-hair brush a layer of this solution is painted over the 
surface of the dried unfixed blood film, upon which it is allowed to act for 
from one to five minutes. The excess is then removed by blotting with a 
bit of filter paper, and the specimen is mounted in cedar oil. Or, as Wolff 
advises, Zollikofer's method may be used : placing the fresh film for a few 
minutes in a stoppered bottle containing crystals of pure iodine. In films 
thus treated the iodine reaction is recognized by a slight or intense, diffuse 
brown coloring of the entire protoplasm, or by the presence throughout the 
protoplasm of numerous intensely stained, reddish-brown granules, the 
latter change being the more common. In normal blood the protoplasm of 
the leucocytes is stained a pale yellow and the nuclei remain almost 
colorless. 

Antibacterial Action of the Blood. — According to Halliburton, 2 "the 
power of the blood to destroy bacteria was first discovered when an effort 
was made to grow various kinds of bacteria in it; the blood was believed 
to be a suitable soil for this purpose, but it was found to have the opposite 
effect in many instances. The chemical characters of the substances which 
kill the bacteria are not fully known. Evidence appears to favor the leuco- 
cytes as the origin of this bactericidal substance. These substances are 
called alexins, but the more usual name now applied to them is that of 
bacteriolysins. The bactericidal power of the blood is closely related to its 
alkalinity. Increase of alkalinity means increase of bactericidal power. 
Alkalinity is probably beneficial, because it favors those oxidative processes 
in the cells of the body which are so essential for the maintenance of healthy 
life-. Normal blood possesses a certain amount of substances which are 
inimical to the life of bacteria. When a person gets run down there is a 
diminution in the bactericidal power of his blood. However, a perfectly 
healthy person has not an unlimited supply of bacteriolysin, and, if the bac- 
teria are sufficiently numerous, he will fall a victim to the disease which 
they produce. In the struggle he will form more and more bacteriolysin, 
and if he gets well, it means that the bacteria are vanquished, and his blood 

1 Wien. klin. Wochenschr., 1897, vol. x. 

2 Paper read before the British Association for the Advancement of Science. 



THE BLOOD. 689 

remains rich in the particular bacteriolysin he has produced, and so will 
render him immune to further attacks from that particular species of bac- 
terium. Every bacterium seems to cause the development of a specific 
bacteriolysin. Immunity can more conveniently be produced gradually in 
animals, and this applies, not only to the bacteria, but also to the toxins 
they form." 

The Blood in Fever. — There is a decided reduction in the number of 
red cells during fever. Whether the fever destroys the red cells or causes 
them to be unequally distributed in the body is the question. Maragliano 
demonstrated a contraction of arterioles during the height of a febrile 
process, followed by dilatation during defervescence. He was able to verify 
these results by noting the effect of antipyretics (Ewing). 

Salkowski demonstrated an -excess of potassium in the blood during 
fever, thus favoring the view that the red cells are destroyed. Senator, 
von Jaksch, and others have shown that febrile processes are regularly 
marked by diminished alkalescence of the blood. When diphtheria anti- 
toxin is injected, the alkalinity of the blood is increased for about twenty- 
four hours. 

The progressive loss of albumin is probably associated with every fever, 
but occurs in a marked degree when the fever is of an infectious origin. 
Diminished resistance of the red cells occurs in the majority of fevers and 
depends on a variety of factors. Variations in alkalinity are frequent and 
considerable in fever, but are not proportional to either the toxicity or to 
the height of the temperature (according to Ewing). 

The question is, Why do almost all micro-organisms which are harmful 
to the body raise-its temperature? and the suggestion has been made that the 
rise of temperature is a defensive mechanism, or, in other words, pyrexia 
is like phagocytosis or chemiotaxis, in some way harmful to the fever- 
producing micro-organisms or their toxins. It does not follow from 
this view that the higher the temperature of the body the better the 
prognosis, for the higher temperature might be taken to indicate that the 
dose of infection was very severe, and that, therefore, the body did all it 
could to resist the invasion; nor, on the other hand, would it follow that 
if the temperature did not rise much, the dose of infection was slight, for 
it might be that the body was feeble and had but little power of raising 
its temperature, and therefore defending itself. 

It is generally believed, and in all probability correctly, that many 
cases of typhoid fever are benefited by cold sponging or by a cool bath. 
Many have hastily concluded that the bath does good because it lowers the 
temperature. But this is probably incorrect. In the first place we must 
remember that the cold sponging or bath does more than lower the tern 
perature; it diminishes the delirium, the tremor, and the prostration. In 
any of these ways it would do good. But, further, Eoque and Weil claim 



690 DISEASES OF THE BLOOD. 

to have shown that "in typhoid fever left to itself the toxic products manu- 
factured by the bacillus and organism are eliminated in part during the 
illness. The urotoxic coefficient is double the normal, but this elimination 
is incomplete and is only completed during convalescence, for the hyper- 
toxicity continues for four or five weeks after the cessation of the fever. 
In typhoid treated by cold baths, the elimination of toxic products is enor- 
mous during the illness. The hypertoxicity diminishes as the general symp- 
toms mend and as the temperature falls, so that when the period of pyrexia 
and convalescence sets in the elimination of toxins has ceased. "' So we 
learn that it is by' no means certain that in typhoid fever the benefit of cold 
baths is due to their antipyretic influence alone, but also to the elimination 
of toxins. We see that clinical medicine affords no evidence that anti- 
pyretics are useful in fever. , 



CHAPTEE II. 

DISEASES OF THE BLOOD. 

ANJE3IIA. 

A deficiency in the number of red blood-cells or of the haemoglobin 
is known as anaemia. As a rule there are two distinct forms : first, con- 
genital; second) acquired. 

Congenital Form. — The foetus in utero is frequently anaemic owing to 
the inherited disease of its mother. Such diseases are blood disorders like 
syphilis, or where a general devitalization occurs, as seen in tuberculosis. 
If the mother while pregnant passes through a severe form of diphtheria, 
typhoid fever, or any other infectious disease, it may result in anaemia of 
her offspring. 

Malarial infection of the mother may also result in an anaemia of the 
baby. A severe haemorrhage due to an operation on the mother during the 
last period of her pregnancy may cause an anaemia of the baby. 

Acquired Form. — This form is due to either an infection of the baby 
or to toxic conditions acquired after birth and independent of the mother. 
Most cases of acquired anaemia seen by me are the direct result of mal- 
nutrition. I have referred in detail to this condition in the chapter on 
"Scurvy" and "Bachitis." 

Splenic Atxmmia (Splexomegalic Cirrhosis of Liver; 
Banti's Disease). 

The characteristic features of this disease consist in progressive enlarge- 
ment of the spleen, later in the disease cirrhosis of the liver with ascites, 
and jaundice. 

Etiology. — An intoxication is probably the cause of this condition. 
Whether it is gastric or intestinal is not easily determined. 

Pathology. — There is a hyperplasia and fibrosis of the spleen, secondary 
anaemia, and cirrhosis of the liver as a terminal development in some cases. 

Symptoms. — As a result of haemorrhages, such as haematemesis or in- 
testinal bleeding, there is a secondary anaemia. Bleeding may not only be 
confined to the stomach and bowels, but it may also be due to gastric erosions 
or varicose veins in the oesophagus. In some cases the gums will bleed. 
There is usually jaundice because of the cirrhosis of the liver, associated 
therewith anorexia. Constipation or diarrhoea may be present. The 
examination of the blood shows nothing definite excepting a leukopaenia and 
a relative lymphocytosis. There is also a haemic murmur which is systolic. 
The slightest exertion will be followed by tachycardia. The urine may eon- 
tain albumin, but no casts, although blood- and pus- cells have been found. 
The temperature is rarely above 100° in the evening, and is usually about 
99° in the morning. The course of the disease is chronic, the treatment 
purely symptomatic. 

(691) 



692 DISEASES OF THE BLOOD. 

Secondary Anemia. 

Causes. — Toxic influences frequently destroy the blood corpuscles and 
also the haemoglobin, hence anaemia results. When haemorrhage takes place 
then anaemia frequently follows. Malaria and whooping-cough seem to 
affect children more than adults. Other diseases, such as rheumatism and 
endocarditis, in fact, most of the acute infectious diseases, cause anaemia. 
Improper hygiene, and more frequently improper food, should not be over- 
looked as causative factors. 

Symptoms. — A pale white skin and waxy appearance of the nails is 
the usual clinical picture. Children do not appear bright. They take no 
interest in their surroundings, and do not wish to play. Loss of appetite 
and tendency to constipation frequently exist. 

Diagnosis. — This is usually determined by the condition of the blood. 

Prognosis. — The origin of the anaemia should be the guide in deter- 
mining the outcome of this condition. Great care should be used in ven- 
turing an opinion, unless we are sure of the origin and can remove the cause 
of same. 

Treatment. — Fresh air, food (chiefly proteids), and restoratives, such 
as codliver-oil, lipanin, iron, Fowler's solution, and malt preparations, are 
indicated. Wine or champagne is sometimes valuable. 

Pernicious Anaemia. 

This rare condition is sometimes seen in children. 

Etiology. — It may follow simple anaemia so that it would appear as 
the result of a continuation of malnutrition. Many theories are offered. 
Tape-worm, syphilis, and rachitis are believed to be the factors causing this 
condition. 

Pathology. — Hunter first reported the presence of a deposit of iron in 
the hepatic cells. There is also an anaemia of the internal organs. Some- 
times capillary haemorrhages are seen in the various organs. Fatty degen- 
eration is also described as a frequent pathological finding. 

General Symptoms. — These are the same as previously described in the 
article on anaemia, although all symptoms are of a more severe type. Epi- 
staxis, in addition to local purpuric spots, denotes the tendency to haemor- 
rhages. An interference of the return circulation to the heart is manifested 
by oedema of the feet and ankles. The urine contains neither albumin nor 
casts. 

Special Symptoms. — The blood will furnish the real means of diag- 
nosis. The haemoglobin may sometimes be as low as 20 to 30 per cent. 
The erythrocytes are reduced in number; 2,000,000 is a fair average red 
blood count in this condition, although Lenhartz 1 refers to a reduction of 



Lenhartz — "Clinical Microscopy/' page 156. F. A. Davis Co., 1904. 



PLATE XXXII 




A. — Progressive Pernicious Anemia. The case ended fatally in six 
weeks ; cause unknown ; possibly in connection with typhoid fever. Ehrlich's 
triacid stain. Zeiss ocular 1, oil immersion 1 / 12 . a, normal erythrocytes; 
6, megalocytes; c, microcytes; d, marked poikilocytosis; e, megaloblast; 
f, polynuclear neutrophilic leucocyte. (Lenhartz-Brooks. ) 

B. — Lienal (Splenic) Leukemia, a, normal erythrocyte; &. nucleated 
erythrocyte, nucleus eccentrically situated; c, polynuclear neutrophilic leuco- 
cytes; d, eosinophilic (myelo) cell. The eosinophilic cell at the top has 
been ruptured and the granula dispersed. Two small greenish-blue nuclei, 
perhaps small lymphocytes. (Lenhartz-Brooks.) 

V. — Lienal (Splenic) Leukaemia. al, megaloblast; a, normal erythro- 
cyte; a2, megaloblast, with anaemic degeneration; &, polynuclear leucocytes; 
c, "marrow cells" (myelocytes); d, large lymphocyte. (Lenhartz-Brooks.) 

D. — Acute Leukemia. This picture is made from two different, rapidly 
fatal, clinically similar cases. The upper portion is stained with Ehrlich's 
stain with eosin-hematoxylin ; the lower portion is stained with the Plehn- 
Chenzinsky's stain. (Lenhartz-Brooks.) 



LEUKEMIA. 693 

erythrocytes as low as 400,000 to 800,000. There is also an enormous 
poikilocytosis. 

In this disease there is a greater reduction in the number of red blood 
cells (oligocythemia) than in any other disease. 

Leukemia (Leukocythjs^ia). 

In this condition we have a reduction of the red corpuscles and a cor- 
responding increase in the white blood cells. 

Cellular forms called lymphocytes not otherwise found in health are 
present in the blood. Yirchow calls this condition "white blood." Ehrlich 
calls it a leucocytosis of a chronic type. 

Etiology. — This is unknown. Some authors, Koux and Lowit, describe 
asporozoa in the blood as well as in the leucocytes and in the spleen. Other 
writers believe that there is a predisposition in syphilitic and rachitic chil- 
dren. Unsanitary surroundings and injury to the spleen are decided etio- 
logical factors. 

The following classification is given by Ehrlich: — 

(a) Lymphatic forms. 

(o) Myelogenous and splenic forms. 

Lymphatic Form. — When the colorless corpuscles are as large as a 
normal erythrocyte then an involvement of the glandular system can be 
diagnosticated. 

Myelogenous and Splenic Forms. — If large cells appear then bone- 
marrow and the spleen evidently participate. When large mononucleated 
leucocytes are found then the bone-marrow is probably involved. If, in the 
field of the microscope, three to five or more cells filled with strongly re- 
fractive spheroid granules are found, the splenic involvement should be 
suspected. 

Pathology. — The lesions are confined to the bone-marrow, lymphatic 
glands, and spleen. The spleen is enormously enlarged, sometimes filling 
half of the abdominal cavity. Sometimes it is soft, and at other times very 
hard on palpation. It has a dark red color. In the lymphatic form any 
or all of the external glands of the body may be affected; thus the cervical, 
maxillary, bronchial, mesenteric, or inguinal glands may be involved. 
There is a simple hyperplasia found in the glands. The liver is usually 
enlarged from an infiltration with lymphoid tissue. The lymphoid tissue 
in the tonsils and the thymus gland have the same changes. Hemorrhages 
are not infrequent. 

Symptoms and Diagnosis. — The disease is usually ushered in by a severe 
hemorrhage, after which profound anaemia and a general weakness are noted. 
The spleen is always enlarged and the lymphatic glands are palpable. The 
glands are movable, but never tender on palpation. The liver is usually 
enlarged. In the beginning there is little or no fever, although later in the 



694 DISEASES OF THE BLOOD. 

disease the temperature may rise as high as 103° F. Sometimes from in- 
volvement of the liver there will be dropsy of the feet or a general anasarca. 
Haemorrhages from the nose, month, stomach, and bowels frequently com- 
plicate this condition. From the loss of blood fainting spells may occur. 

The Blood. — The characteristic feature is an increase in the number 
of leucocytes. The normal ratio between the red and white corpuscles varies 
between 1 to 500 and 1 to 1000. In leukaemia the ratio is so altered that 
we may have one colorless corpuscle to twenty, or even to five, red corpus-' 
cles. Some authors report a ratio of one red to two white corpuscles. 

The eosinophiles are frequently increased many times their normal 
number. A characteristic feature is the presence of large and small mono- 
nuclear lymphocytes. Ehrlich describes a large mononuclear nutrophilic 
staining cell which normally exists in the bone-marrow, and is found in the 
myelogonous form of leukaemia. It is called the myelocyte. 

Treatment. — The nutrition of the child must be carefully considered. 
Albumin and the cereals should form the main portion of the food. All 
vegetables should be ordered. If the child can be taken out of doors, then 
the same should be insisted upon. Strict attention to hygienic details will 
greatly assist in modifying this condition. 

Medication. — Iron, arsenic, in the form of Fowler^s solution, cod- 
liver-oil, and malt extracts should be given. If there is anorexia then 
strychnia or nux vomica should be given. 

pseudo-leuk^mio anaemia of infancy (anemia infantum 
Pseudo-Leuk^mica) . 

Von Jaksch was the first to describe this disease in 1889. It is an 
infantile anaemia characterized by the following conditions : — 

1. There is a marked enlargement of the spleen. 

2. A slight enlargement of the liver and the lymph nodes. 

3. A marked reduction in the number of red corpuscles. 

It is usually a secondary anaemia rather than a primary disease. 

Etiology. — The disease is usually found in infants and children be- 
tween 6 months and 4 years of age. 

Monti and Berggrun collected 16 cases in 1892. Pickets, congenital 
syphilis, chronic intestinal catarrh, and tuberculosis were found in cases 
collected by Fischl. 

Pathological Anatomy. — The sp]een is enlarged and rather firm. 
Histologically, the changes are those of simple hyperplasia of all elements, 
while the sinuses contain no excessive number of leucocytes. Baginsky 
found many eosinophile cells in the spleen. The changes in the viscera are 
described by Von Jaksch, Eppinger, Luzet, Baginsky, Audeoud, and 
Rotch. 



CHLOROSIS. 695 

The marrow, according to Luzet, is diffusely reddened and moist and 
shows evidence of excessive multiplication of the red cells. 

The Blood. — Leucocytosis is an important symptom. The white blood 
cells number between 20,000 and 50,000. Other cases (Baginsky) between 
40,000 and 122,000. 

According to Monti, the proportion of white cells to the red may be 
as 1 to 100 or 1 to 15. 

Symptoms. — After a prolonged gastro-intestinal disease an infant will 
appear very anaemic. Fever is not usually present. When fever is pres- 
ent the cause of the same will usually be found other than in the spleen. 
Icterus is sometimes present. 

There is a decided loss of appetite and the bowels move sluggishly. 
The skin has a yellowish color and is intensely anaemic. The abdomen 
appears distended. The liver is slightly enlarged. The lymph glands are 
palpable. The spleen is very much enlarged and occupies the left hypo- 
chondrium, reaching at times to the crest of the ilium. 

Prognosis. — The prognosis is poor, although recovery does take place 
in some instances. A case of this kind seen by me has shown marked im- 
provement under anti-rachitic and restorative treatment. 

Treatment. — Tonic doses of iron, quinine, and strychnine served me 
well. Codliver-oil and the glycerophosphites ol lime and soda are indi- 
cated. Phosphorus has been recommended by some. The bowels must be 
thoroughly cleansed, and the general peristalsis stimulated. Nux vomica, 
in 1-minim doses three times a day, when anorexia and gastric atony are 
present. Fresh air and general hygienic management, in addition to a 
supporting diet, will do more toward building up and restoring the system 
than all medication combined. 

Chlorosis. 

Chlorosis, sometimes called chloroanaemia, occurs in girls about the 
period of puberty. There is extreme pallor of the mucous membrane, pale 
and greenish tint to the skin, .and a pearly eye. Associated therewith is 
extreme lassitude, a tired feeling, and either suppression or irregularity 
of menstruation. There is a venous hum which can be plainly heard in the 
vessels of the neck. On the slightest exertion there will be dyspnoea, pal- 
pitation, and dizziness. As a rule, such children do not emaciate; they are 
rather well nourished. Owing to a freaky appetite, the bowels are irregular 
and usually constipated. The urine frequently contains indican, and some 
observers believe that the intestinal toxaemia is an important factor in the 
causation of this disease. 

Etiology. — Sedentary occupation associated with lack of exercise, or 
poor hygienic surroundings, may induce this condition. Nervous girls, 
susceptible to mental influences, such as fright or worry, are more prone 



69 G DISEASES OF THE BLOOD. 

to the development of this condition than robust, healthy girls. Auto- 
intoxication is certainly a factor, as I have frequently seen chlorosis in 
girls suffering with chronic constipation. 

Pathology. — Distinct pathological lesions cannot be attributed to this 
condition. In some cases ulcer of the stomach is associated, and this latter 
condition may be fatal. 

Symptoms. — The appetite is poor and such girls invariably crave for 
sour and spiced foods to stimulate the appetite. Constipation is almost al- 
ways present. Headache and other nervous symptoms are also present. Such 
girls are very emotional, and cry and laugh very easily. They are very 
sensitive. A venous murmur can usually be made out in the vessels of the 
neck. There is a blowing systolic murmur which can be heard over the 
heart in the mitral region and also in the region of the pulmonary artery. 
Venous thrombosis is most frequently seen in the femoral veins, and vari- 
cose veins are sometimes seen over the thighs and ankles. Menstruation is 
irregular and the flow is scanty or very profuse and sometimes painful. 
There is a decrease in the percentage of haemoglobin and also a decrease in 
the number of red corpuscles. The red cells may be reduced to 4,000,000. 

The spleen may be slightly enlarged, but on this symptom no reliance 
can be placed. A puffmess of the face or oedema of the ankles due to a 
sluggish return circulation is occasionally seen. 

When localized areas of pain are complained of in the region of the 
stomach, then gastric ulcer should be suspected. 

Diagnosis. — Chlorosis is met with in girls only at or about the period 
of menstruation. This is its characteristic diagnostic feature. Such chil- 
dren, as a rule, are fat and look well nourished. 

Prognosis. — This is always good, although the disease may last several 
years. If chlorosis is a forerunner of tuberculosis or gastric ulcer, then a 
fatal termination may occur. The outcome of a case depends on heroic 
restorative treatment. 

Treatment. — Hygienic Treatment: Eemove the child from its imme- 
diate surroundings, from the city to the country. If chlorosis occurs in a 
girl living at a boarding-school, in a convent, or in a girl working in a 
factory, the hygienic conditions demand : — 

1. To sleep in an airy room with the windows open at night. 

2. Discontinue working, or studying if at school, to procure mental 
rest. 

3. Change the entire mode of living, so that there is neither care nor 
worry for the chlorotic girl. 

Exercise. — Gentle exercise, walking, swimming, the lighter exercises of 
physical culture followed by a shower-bath and massage are valuable. Fric- 
tion with a coarse towel after the daily sponge bath is useful to stimulate 
the circulation. Eeading or sewing at night must be forbidden. 



CHLOROSIS. 



697 



Nutrition. — To stimulate metabolism nothing equals food. Proteins 
in the form of milk, meat, eggs, cereals, cream, butter, and cheese should 
be liberally given. All fresh fruits may be allowed. Eegularity in feeding 
must be demanded, although a drink of milk, buttermilk, cocoa, or zoolak 
may be taken between meals. 







\<y 



P o 






fc*>" 



pf 



r> 



Fig. 226. — Blood from a Case of Chlorosis. Girl 16 years of age. Red cells 
appear pale (achromia) and vary considerably in size. (Original.) 



Medicinal Treatment. — Soluble preparations of iron, such as ovoferrin 
or peptomangan, may be given in teaspoonful doses after each meal. Arsenic 
in the form of Fowler's solution or arsenious acid may be combined with 
the iron. The arseniated hsemaboloids have been tried by me with good 
result. Maltine with or without hypophosphites may be tried three times a 
day. Codliver-oil, morrholine, or lipanin may be tried in teaspoonful doses 
three times a day given after meals. The sun bath or the electric light 
bath may be tried in conjunction with the above-described treatment. 



CHAPTER III. 
ACUTE RHEUMATISM (POLYARTHRITIS). 

This disease is sometimes known as rheumatic fever, also as inflam- 
matory rheumatism. It is an acute, infectious, but non-contagious disease. 
The infection is characterized by an inflammation which localizes in the 
joints, and travels from joint to joint, evidently through the circulation. 
The most frequent complication is endocarditis. 

Etiology. — The specific factor is evidently a micro-organism. A great 
many observers have studied this subject, among them, Leyden, Sahli, 
Achalme, Riva, Triboubet, Coyon, Singer, Jaccoud, and many others. A 
bacillus described" as an anaerobic, with more or less motility, similar to the 
anthrax bacillus, has been described by Achalme. This bacillus, when in- 
jected into animals, has reproduced symptoms resembling rheumatism. 
Thus this observer believes he has found the specific agent causing this 
disease. 

Other causes have been described as the result of defective assimila- 
tion, which produces lactic acid or combinations of it. Another theory 
is the so-called nervous theory, in which the nerve centers are primarily 
affected by cold, and the local lesions are atrophic in character. 

This nervous disturbance brings about hurtful metabolism, so that the 
nitrogenous products, instead of being converted into urea, are transformed 
into uric acid and other poisonous products which cause these symptoms. 

Whether or not heredity bears any relationship to the cause of this 
disease may be considered by the fact that in two-thirds of the cases, dis- 
eases of a similar type can be traced to the ancestors. Goaty parents 
will usually have rheumatic children. The disease is very common in 
children, and has also been observed in nurslings. 

Rheumatism occurs more often in the spring of the year. When the 
disease has commenced, it usually lays the foundation for future attacks; 
in other words, one attack of rheumatism predisposes to future attacks of 
the disease. 

The tonsils have frequently been looked upon as the seat of entrance 
of this disease ; thus acute tonsillitis has frequently been followed by acute 
articular rheumatism. In the same manner endocarditis has frequently 
followed an attack of tonsillitis. It is therefore safe to assume that" the 
specific entrance of an infection can originate in a diseased tonsil. 

Packard has described a series of cases of endocardial inflammation 
(698) 



ACUTE RHEUMATISM. (599, 

following tonsillitis. He regards a serous inflammation as due to the germs 
or other- toxins entering the circulation through inflamed tonsils. 

Bacteriology. — Triboulet and Coyon 1 give the results of their bac- 
teriologic examinations in 11 cases of acute articular rheumatism. The}' 
discovered in all these cases a diplococcus or . diplobacillus which they state 
cannot be well described as to its cultural peculiarities, as its growth is so 
irregular. 

The organism exhibits great plesiomorphism and resembles most closely 
in character the diplococcus pneumonias, but differs from it in that it can 
be kept alive for a considerable length of time, and that it is not patho- 
genic for mice. The organism is extremely pathogenic for rabbits, and 
the authors give a detailed account of its effects on a rabbit. The animal 
died twenty days after intravenous inoculation. Death was due to heart 
failure resulting from an absolute mitral insufficiency. During life there 
was an oscillatory temperature. The autopsy showed fresh pleuritis and 
pericarditis, and an acute vegetative endocarditis with tremendous masses 
of vegetations on the mitral valve. The vegetations microscopically showed 
many diplobacilli similar to those originally inoculated, and cultures from 
the organs also showed it. Other rabbits inoculated with smaller doses from 
other cases showed irregular fever, disturbances of the heart, and pleurisy, 
but did not die. 

Symptoms. — The symptoms are entirely different from those met with, 
in adults. The fever is not so high, usually between 100° and 102° F. 
The swelling of the joints is moderate, and there is not the redness and 
inflammation visible to the eye as we see it in adults. The pains are not 
severe in all cases, and there are less joints involved as a rule than we 
find in adults. AVe therefore meet with a great many cases of rheumatism 
that walk around suffering slight pains. Sometimes the lower extremities 
are affected, at other times the disease is limited to the upper extremities. 
A child may walk apparently lame or an infant may cry when put on its 
feet. Jacobi years ago directed the attention of the profession to the 
necessity of carefully watching every case of so-called "growing pains. " 
He believed, and correctly so, that the majority of these cases were in 
reality rheumatism. The most frequent symptoms are vomiting, fever, gen- 
eral malaise, anorexia, in addition to multiple arthropathy. 

Rheumatism a Seouela to Tonsillitis. — That rheumatism is irequently 
a sequel to tonsillitis has been noted by many observers. Packard, of Phila- 
delphia, has reported a series of cases in which the throat was first affected 
and later heart disease was distinctly manifested. Emil Mayer, of Xew 
York City, has also reported a series of cases in which the tonsils were the 



1 Comptes Rendus de la Societe de Biologie, February 4, 1898. 



yOO DISEASES OF THE BLOOD. 

portals of infection. This is certainly not a theory when we study the 
primary infection and follow it up with its secondary result. 

Sir Willoughby Wade 1 says, in relationship between tonsillitis and 
rheumatic fever, he believes that tonsillitis is a primary infective disease 
of the lacunas; rheumatic fever a secondary disease arising from the 
absorption of microbes or their products into the system. Knowing this 
to be a factor, it would only seem proper to treat every tonsillitis as vigor- 
ously as possible. 

Acute Contagious Articular Rheumatism. — G. B. Allari reports 3 
cases which were characterized by contagiousness and at the beginning of 
the disorder with angina of the throat. In the fourth case the angina re- 
appeared with every reappearance of exacerbation of the articular symptoms. 
Bacteriological investigations of the exudate on the tonsils showed in each 
case a streptodiplococcus which was almost identical in structure and be- 
havior with that found by Mayer in the same affection. Animals inoculated 
with this micro-organism developed lesions in the joints. 

Subcutaneous Tendinous Nodules. — Barlow and Warner described this 
manifestation of rheumatism in 1881 as oval semi-transparent fibrous bodies 
like boiled sago grains. They are most frequently met with at the back of 
the elbow, over the malleoli, and at the margin of the patella. Occasionally 
on the extensior tendons of the hands, fingers, and toes, or over the spinous 
processes of the vertebras. They are composed of fibrin, cells, and fibrous 
tissue. They vary in size from a pin-head to a small bean, though some- 
times being as large as an almond. They may remain for months, although 
they frequently disappear in a few weeks. Cheadle states that they can be 
seen if the skin is tightly drawn. Cheadle has also shown the intimate rela- 
tionship between erythema and rheumatism. 

Purpura. — This is frequently met with in the course of rheumatism. 
It is a rash of a deep purplish hue and is most probably a result of rheu- 
matism. 

Complications. — The most frequent form of complication is endocar- 
ditis. Fully 75 per cent, of my cases met with in a large outdoor practice 
showed this form of complication. This complication has frequently been 
the first symptom that led to the discovery that our patient had rheuma- 
tism. 

Pericarditis is rarely seen in children under 7 years of age. It is 
usually associated with endocarditis. 

• Pleurisy, peritonitis, or meningitis may complicate rheumatism. 
Chorea frequently associates itself with rheumatism, so that a great many 
authors believe that there is an intimate relationship between rheumatism 
and chorea. 



1 British Medical Journal, 1898. 



ACUTE RHEUMATISM. 701 

Holt states that in a series of cases of chorea observed by him, 56 
per cent, gave evidence of the rheumatic diathesis. 

Prognosis and Course. — The course of rheumatism depends on the 
treatment. Pains in the joints should never be regarded as a trivial 
matter. How frequently do we see a child suffering with what the mother 
calls "growing pains/' and a few weeks or months later we note shortness 
of breath due to heart trouble, usually endocarditis. It is better to put a 
child to led than to run risks of such a serious complication. The prog- 
nosis depends on the care bestowed, although we know that this disease has 
a tendency to assume a chronic course. However, a case with proper treat- 
ment should recover entirely. The inflammatory stage lasts from ten days 
to two weeks. Cases of inflammatory rheumatism complicating scarlet 
fever or diphtheria lasting between three and eight weeks have been seen 
by me during my hospital service. 

Rheumatism in children assumes the course of a general infectious 
malady. The intensity of cardiac complications cannot be approximated 
by the intensity or mildness of articular manifestations. Many authorities 
state that the percentage of cardiac complications is between 81 and 87 
per cent. 

Lethal termination will frequently show pericarditis, hence the im- 
portant deduction is to prevent such complications, if possible, by proper 
prophylactic treatment. 

Treatment. — The first thing to do is to put the child in bed. The 
patient should be kept in bed until every particle of pain and fever is gone. 

1. When the disease is localized we can treat the same and try to 
destroy as much of the pathogenic infection as possible. 

2. The important point would be to restore the subnormal condition at 
the time of the invasion of these infective germs, and prevent thereby the 
absorption of the toxins generated from these micro-organisms. 

3. Watch for possible complications. While it is true that we can 
limit by local treatment the spread of active infective processes, on the 
other hand, when the body is weakened from anaemia, or from other de- 
pressing influences, this infection will spread in spite of the most vigorous 
local treatment. 

Eest must be enjoined, more so in children with this disease than in 
most other diseases. We must aim to have the most perfect physiological 
repose. In this way we have the longest interval between the systoles and 
we keep down the blood pressure. 

Prophylactic Treatment. — In trying to prevent rheumatism the hy- 
giene of the skin requires careful attention. 'The body should be properly 
protected, due allowance being made for sudden changes in the weather. 
Too much clothing means overheating. Perspiration induced thereby in- 
vites this disease when the surface is suddenly chilled. Overheated apart- 



702 DISEASES OF THE BLOOD. 

ments render children peculiarly susceptible to this disease. Proper ven- 
tilation, without incurring any draught, is urgently demanded. Cool or 
tepid bathing or sponging has a very good effect on the skin. Unneces- 
sary and useless hardening of children*, by exposing them to cold baths in 
cold rooms, without proper protection, will certainly invite this disease. 

Dietetic Treatment. — Milk and milk foods; cereals and fruits, espe- 
cially acid fruits ; broths and all soups made from meat are indicated. For 
thirst, buttermilk, and all fermented milks, seltzer and milk, alkaline waters, 
lithia, apollinaris, white rock, lemonade, and orangeade. 

Medicinal Treatment. — The alkaline treatment known as Fuller's 
method has been abandoned many years ago. The first thing to do is to 
cleanse the gastro-intestinal tract. A wineglassful or more, depending on 
the age of the child, of citrate of magnesia, repeated every two hours, until 
its effect is produced. Khubarb and soda, 5- to 10- grain doses, or calomel, 
is valuable. Salicylate of soda, 3 grains every three hours, for a child 3 
years old. Older children in proportion. This treatment should be con- 
tinued two or three days, if the drug is well borne : — 

IJ Natr. salieylat 1 drachm 

Elix. lactopeptin 2 ounces 

M. Sig. : One drachm every three hours may be given. 

Salol or salophen, in doses of 2 to 5 grains, is indicated. Aspirin or 
novatophan in doses of 3 to 10 grains may be given every three hours. 
Cotton saturated with the oil of wintergreen applied over the affected 
joints, the whole covered with oil-silk, is recommended. 

Fever. — Fever requires the same treatment in this disease as in all 
others. Cold sponging of the surface will do good. 

Restorative Treatment. — The profound anasmia caused by this disease 
is an indication for early restorative treatment. We should therefore aid 
nutrition by giving cream, butter, and, if tolerated, codliver-oil, with or 
without malt. Iron and iodide of sodium are good restoratives. Fellows' 
syrup of the hypophosphites may be tried. The application of leeches, 
blisters, or sinapisms sometimes does good. Ice-bags applied over inflamed 
joints will reduce swelling, remove heat, and have a very soothing effect. 

An ice-bag applied over the heart if endocarditis complicates has served 
me quite well in some cases. For the management of heart complications, 
see chapter on "Heart Diseases." 

It is vital to stimulate the action of the kidneys. For this reason I 
have previously mentioned the alkaline mineral waters. If a diuretic is 
indicated none is better than Basham's mixture. See formula in chapter 
on "Scarlet Fever," page 627. 

The following ointment is useful applied on gauze to the affected 
joint: — 



MUSCULAR RHEUMATISM. 703 

Ifc Methyl salicylate 1 part 

Vaseline 10 parts 

Mix. 

Apply morning and evening. 

Warm Bathing. — By adding sulphur in the form of kalium sulphuret, 
about 1 ounce to an infant's bath-tub of water, and bathing the affected 
joints at a temperature of 95° to 100° F., is sometimes very grateful and 
well borne. It is not advisable to make sudden changes in the local treat- 
ment. If ice-bags have been used and are well borne, they should be 
continued. Sulphur baths, so also pine-needle baths, are very grateful in 
the evening, and sometimes promote sleep. When pains are very severe, 
full doses of codeine or chloralamid may be given. It is seldom that so 
much truth is contained in a single sentence as in the following from 
Cheadle: "The various manifestations of rheumatism massed together in 
the case of adults tend to become isolated in the case of children, so that 
the whole phenomena are distributed over years instead of weeks or months, 
and the history of a rheumatism may be the history of a whole childhood " 

Muscular Eheumatism (Myalgia). 

This painful condition is rarely seen in children. It is characterized 
by pain when the muscles affected are brought into play. When the dis- 
ease affects the muscles of the neck it is called acute torticollis. When the 
intercostal muscles are affected it is called pleurodynia. When the lumbar 
muscles are affected it is called lumbago. Peculiar contractions of the 
muscles frequently follow persistent muscular rheumatism and sometimes 
cause permanent deformity (see chapter on "Torticollis"). Infants so 
affected usually cry when the group of muscles involved are moved. There 
is no fever present. 

R. K., 16 years old, was attacked with a severe tonsillitis. The cervical glands 
were enlarged and tender on palpation. Creosote inhalations and unguentum Crede 
rubbed into the glands of the neck relieved this condition. Two days later after 
going out into the street she had violent muscular pains involving the back, groin, 
and muscles of the thigh. It was a distinct lumbago and a general myalgia. There 
was also a painful sciatica. With the aid of massage and the internal administra- 
tion of 5 grains (0.3) salophen every four hours these pains gradually subsided. 
After these pains left there were pains involving the intercostal muscles, so that we 
had a lumbago followed by pleurodynia. Rest in bed, warmth, and massage relieved 
this condition permanently. 

Treatment. — Local treatment consisting of massage aided by gentle 
faradic electricity is very useful. Warm, moist fomentations, such as flax- 
seed meal poultices, are very soothing and seem to do good. The internal 
administration of salicylate of soda has not seemed to benefit my cases. 
Codeine in V 10 to y i5 -grain doses, repeated every two or three hours, can 



704 DISEASES OF THE BLOOD. 

be given until the pain ceases. In some cases chloral hydrate combined 
with bromide of sodium will afford relief. Eubbing the affected muscles 
with ol. hyoscyamus seems to relieve. 

Torticollis (Wry-neck). 

This condition is caused by the spasm of one sterno-cleido-mastoid 
muscle. Sometimes there may be a spasm of the posterior cervical muscle, 
including the trapezius. 

Etiology. — Congenital torticollis is a rare condition. When it is 
present it is due, according to Whitman, to a constrained condition in 
utero. 

More common than the congenital condition is the acquired torticollis. 
The following is Wnitman's classification: — 

1. The acute. 2. The chronic. 

Acute torticollis (traumatic torticollis) may be divided into three 
classes : — 

(a) "Stiff, neck," due to "cold" or to rheumatism. 

(o) Distortion caused by strain or other injuries. 

(c) Distortion due to irritation of the peripheral nerves as following 
"sore throat," or secondary, to enlarged or suppurating cervical glands, and 
the like ("reflex torticollis"). 

The ordinary stiff-neck is of but slight importance. The traumatic 
wry-neck is efficiently treated by support. Keflex torticollis is by far the 
most important of the forms of acute torticollis, and it is the usual cause 
of persistent distortion. 

Chronic Torticollis. — From the clinical standpoint, both the congenital 
and the reflex torticollis, after the acute stage has passed, are forms of 
chronic torticollis; the class includes also those forms in which the onset 
has not been accompanied by pain. 

Rachitic torticollis, usually a postural or compensatory distortion 
caused by deformity of the spine. 

Ocular torticollis, caused by defective eyesight. 

Psychical torticollis, a functional or hysterical deformity. 

Spasmodic torticollis, a convulsive tic — rather a form of nervous dis- 
ease than a simple deformity. 

Any irritation of the spinal accessory nerve or its branches may bring 
on this spasm. Whitman 1 gives the following statistics of 264 cases ex- 
tending over nineteen years, torticollis from Pott's disease not being in- 
cluded: Males, 109; females, 155; congenital, 32; under 2 years, 33; 
from 2 to 10 years, 153; over 10 years, 46; acute (less than two months' 



1 Report for Hospital of Ruptured and Crippled, New York. 



PURPURA. 705 

duration), 77; chronic, 60, of which number 22 had lasted over two years 
or longer. 

Holt believes that an enlarged cervical lymph gland irritating the 
spinal accessory nerve can bring on this spasm. He also mentions malaria 
as a cause. I have observed similar conditions. In several of my cases 
the spasm was present when malarial infection existed, and subsided when 
quinine was given. Torticollis has also been observed by me after the 
sudden chilling of the body. 

Symptoms. — The head is drawn to the affected side. If the trapezius 
is affected there is slight rotation of the head, but if the trapezius is not 
affected the head is rotated toward the healthy side. 

A child 6 years old was taken on an open car. She was in a healthy condition, 
appetite good, bowels regular, apparently nothing wrong. She complained of being 
cold and on the following day had a wry-neck. Salicylate of soda, in 5-grain doses 
three times a day, and massage of the sterno-cleido-mastoid with spirits of camphor 
seemed to relieve the pain. The best result was obtained by the use of a mild 
faradic current. The condition lasted about nine days. The child was discharged 
cured. 

The above case illustrates the form commonly described as rheuma- 
tism or "rheumatic torticollis." 

Treatment. — Medicinal and Local: Early treatment means success. 
Delayed treatment means disappointment in most instances. When specific 
causes exist, such as malaria or rheumatism, they should be treated by 
specific remedies. In every case warmth, as flaxseed poulticing and mas- 
sage, will do good. Sometimes the application of iodine over the affected 
muscles will do good. 

Surgical Treatment. — Lorenz describes the fine results attained by sub- 
cutaneous intentional rupture of the sterno-cleido-mastoid muscle to cure 
obstinate wry-neck in children. The subject lies with a hard cushion under 
the shoulders, the head and neck unsupported. The shoulder is drawn down 
at the same time and it is thus possible to tear the muscle by gradual de- 
hiscence, followed by over-correction. Parents accept this operation much 
more readily than when the knife is used, and the dehiscent fibers heal 
under the intact skin with little if any cicatricial formation. The cure has 
been ideal and permanent in all his cases. 

Purpura. 
Haemorrhages into the skin or mucous membrane are designated as 
purpura. When small they are called petechial; when large they are called 
ecchymoses. Purpura is frequently associated with the infectious diseases. 

Martha B., 7 years old, was brought to the Willard Parker Hospital August 31, 
1903. She had been ill two days before admission. The diagnosis of nasal diphtheria 
was made. On admission the pulse was 158. Two days later it dropped to 90, and 
on the third day the pulse-rate sank from 96 to 66. A general purpura was notice- 



706 



DISEASES OF THE BLOOD. 



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able. There were bluish diseolorations of the skin visible on the extremities. Dr. 
Burckhalter, the resident physician, called my attention to a hematuria. The case 
ended fatally. 

Purpura Hemorrhagica (Morbus 
Maculosus Werlhofii.) 

This is the most severe form of 
purpura. The lesions are a series of 
haemorrhages confined to the mucous 
membrane and skin. On the skin 
purpuric spots are seen which de- 
note haemorrhages. These haemor- 
rhages are seen in the lower and up- 
per extremities ; also on the face and 
abdomen. The conjunctival mu- 
cous membrane shows ecchymotic 
areas. The gums bleed easily and 
there are hemorrhagic areas on the 
soft and hard palate. Hematuria 
and haemoptysis are sometimes seen. 
Diagnosis. — The only disease 
that might be taken for purpura is 
scurvy, but the general history of 
the case associated with malnutri- 
tion will clear up any doubt. 
Treatment. — Best, iron, small doses of ergot and hydrastis internally, 

lemons, oranges, and a nutritious diet. Aromatic sulphuric acid in 5-drop 

doses, several times a day, should be. remembered. 

Purpura Kheumatica (Peliosis Eheumatica: Schonlein's Disease). 

The association of haemorrhages with affections of the joints charac- 
terizes this disease. It has frequently been noted that there is tenderness 
in the joints during the course of simple purpura. But the more pro- 
nounced form of fever, in conjunction with swellings and tenderness of 
the joints, plus the characteristic appearance of the subcutaneous hemor- 
rhages appearing in purpuric spots, differentiate peliosis from simple pur- 
pura. 

Associated with this rheumatic affection we frequently have extravasa- 
tions of blood and serous effusions into the joints, giving a decided fluc- 
tuating feeling. One very important point is the fact that cardiac lesions 
do not complicate this condition. Cases of this kind have frequently been 
reported, and Baginsky lays stress on the non-existence of heart lesions 
in this affection. 



Fig. 227. — Malignant Purpura Compli- 
cating Nasal Diphtheria. General sepsis. 
Toxic .Nephritis, meningitis, myocarditis. 
Note pulse. Fatal. (Original.) 



PURPURA. 707 

The following case came under my observation 1 : — 

A child, George P., about 9 years old, was attacked with pains in his feet and 
cried when attempting to walk. He had had some very violent exercise during the 
four or five weeks preceding this attack by riding a bicycle as much as four and five 
hours daily. The mother stated to me that he had frequently complained of joint 
pains, but she attributed them to "growing." She noted, however, that after bicycle 
riding the boy's pain was much more intense. His general condition was otherwise 
healthy. The examination gave me the following status: — 

A very well nourished boy: muscular and adipose tissues quite well developed, 
and very tall for his age. His weight was 84 pounds. The examination of the 
thorax showed both heart and lungs normal; no cough; heart sounds regular, 
strong; pulse, 96. The temperature was 100.2 in the rectum, and respiration 36. 
The tongue was slightly coated; appetite good; bowels always inclined to constipa- 
tion; but recently since riding the bicycle, very much improved. Intellect free, and 
the boy is mentally well developed. 

The examination of the joints showed severe tenderness and swelling in both 
knees and ankles; slight pain on palpating or rotating the hip joint. The most 
marked tenderness and swelling was found at the knee joints. The upper extremi- 
ties — shoulder, elbow and wrist — were perfectly normal, as far as palpation and 
inspection could demonstrate. The eruption on the skin was of a purplish or bluish 
color, and looked like a distinct subcutaneous haemorrhage. It was confined to the 
Jower extremities, covering almost completely the inner portions of both thighs, the 
ankles, and more especially the calves of both legs. The spots were very irregular in 
outline, in some places confluent, resembling more particularly the eruption of 
morbilli. 

The child was put to bed, the joints were rendered immobile by applying woolen 
roller bandages over them, and locally over each joint some salicylic collodion, 10 per 
cent., was applied with a camel's-hair brush. 

The main point in the treatment which I laid stress upon was to have absolute 
rest, and it was for this reason that I put the child to bed, that I painted salicylic 
collodion, and that I put a roller (flannel) bandage on the legs and covered both 
limbs from the toes to the hip joint. Internally I gave ergotine, 1 / B0 grain every four 
hours, besides 15 drops of tinct. ferri acet. aeth. in water after each meal, three 
times a day. The spots gradually changed from a deep bluish color to a brown; 
then after ten days to a light yellowish color, and after twenty-seven days they could 
scarcely be seen with the naked eye. 

This case has a very interesting clinical history. The question that arose in 
my mind was: Did the violent exercise on the bicycle cause the inflammation of 
the joints and possibly also the subcutaneous haemorrhages? On looking over the 
previous history of the child, I found that he had been well nourished, breast-fed 
until eleven months, and then weaned; commenced walking at 1 year, and talking at 
same age. Dentition began at seven months, and when eight months had two lower 
and two upper incisors ; the child had seven teeth at eleven months, at time of wean- 
ing. 

There is no sign of rickets, although there is a large belly, rather pendulous, 
and the previous history of constipation. The ribs are normal, the long bones well 
developed; spine and thorax as good as desired. I could obtain no data concerning 
time of closure of fontanels. There is no history of haemophilia; no previous bleed- 
ing; no epistaxis; no haemoptysis; both parents of the child living, and both 

1 Pediatrics, vol. ix, No. 10, 1900. 



708 DISEASES OF THE BLOOD. 

healthy. The child has had measles, complicated with bronchitis, when 3 years old, 
lasting in all about one month. No disease previous to this; no summer complaint, 
and nothing since that time. 

There is no evidence of scurvy; teeth are well developed, perfectly normal; the 
gums are healthy. The mother had two other children — one now nursing and one 
4 a /a years old. She has had no miscarriages; no reason to suspect lues. 

I believe the etiological factor in this case was the traumatic element, namely, 
the violent exercise causing both the haemorrhages and the inflammatory affection of 
the joints. 

Henoch's Purpura. 

Hemorrhagic areas confined to the abdomen and lower extremities 
are sometimes seen. There is also vomiting and abdominal symptoms, 
such as diarrhoea (bloody stools) and colicky pains. There is marked 
distension of the abdomen and pains in the joints. This condition 
resembles that which has already been described in the article on "Purpura 
Eheumatica." 

LlTH^MIA (LlTHURIA). 

Haig and Eachford have given us a very clear conception of this con- 
dition, which is simply an excess of uric (lithic) acid in the blood. Haig 
designates this condition as uricacidamria. Other writers call it lithuria. 
Eachford calls this "leucomain poisoning." 

Etiology. — When this condition is met with in children, we can usually 
look to the lithsemic ancestors for the origin of the disease. Imprudent 
diet, such as excess of proteids, may be a factor. Sedentary life and lack 
of proper metabolism invite this condition. The alloxuric bodies are ex- 
creted by the skin, kidneys, and intestinal canal. These bodies are removed 
by the kidney cells from the blood into the urine. When they are in excess 
they must, therefore, have been present in solution in the blood before their 
elimination. 

The presence of uric or lithic acid, xanthin, hypoxanthin, hetero- 
xanthin, and paroxanthin are the factors causing this trouble. We are 
still in the dark concerning the manner in which these bodies act. 

If the kidneys are diseased these bodies are retained and the skin is 
called upon to do the work which the kidneys fail to do. Thus it is that 
hot baths which promote diaphoresis eliminate through the skin, in addi- 
tion to stimulating the action of the kidneys. 

Symptoms. — The new-born lithsemic infant frequently eliminates an 
excess of urates during the first few days of life. In such infants crystals 
of uric acid may be precipitated into the tubules of the pyramids of the 
kidney. Jacobi says that these uric acid infarctions may subsequently be 
washed out of the tubules and serve as the nuclei of urinary calculi. 

Nocturnal incontinence is frequently a symptom of lithaemia. True 



PLATE XXXIII 




t 



Henoch's Purpura. Note ecchymotic spots on lower 
extremities. (Original.) 



LITH^MIA. 709 

arthritic gout resulting from uratic deposits in the tissues about the joints 
is very rare in childhood. 

Fever, crying while the child passes urine, scanty urine which usually 
deposits a reddish sand on the diaper, and irritation of the external genitals 
are the symptoms which appear at the time of urination. The urine is 
very acid and we speak of this condition as "a uric acid form of lithsemia." 
Sometimes there are gastro-enteric manifestations, such as vomiting, head- 
ache, gastric pain, convulsions, a sickening odor of the breath, and consti- 
pation. These gastric symptoms bear no relation to improper diet. They 
are usually met with in children who are carefully guarded as to the diet. 
Such children are extremely nervous and irritable. Eczema is a very com- 
mon manifestation of this condition. Unless a proper understanding of 
this condition exists it will persist and be difficult to relieve. 

The urine in lithcemia is high colored; the specific gravity increased. 
On standing, there is a sediment of red sand (urates). If the urine is 
examined immediately after a paroxysm then the poisonous xanthin bodies 
previously mentioned may be found present. Transient albuminuria is 
occasionally met with. 

Treatment. — The diet is the most important part of the treatment. 
Cereals must be given ; beef juice, soups, broths, and fruits. No alcoholics 
should be given; in fact, all rich and heavy articles of food must be ex- 
cluded. Meat must be given sparingly. Salads and gravies are objection- 
able. Infants require massage. This passive form of exercise will stim- 
ulate the circulation. If children are old enough to exercise, then exercise 
should form an important part of the treatment. 

Drug Treatment. — Calomel should always be given in the commence- 
ment of the treatment. We must aid in keeping the bowels loose during 
the whole course of treatment. 

Salicylate of soda and salol are useful eliminatives. Phosphate of 
sodium and benzoate, especially if eczema exists, are valuable. Alkaline 
waters, such as white rock and apollinaris, may be given ad libitum. 
The Carlsbad waters have the same eliminative effect. Dilute hydrochloric 
acid or dilute phosphoric acid in 3 to 5-drop doses before meals is es- 
pecially indicated when severe headache and gastric symptoms exist. 
Urotropin in 2-grain doses may be given in tablet form. 

HAEMOPHILIA. 

This is usually an inherited condition. It is characterized by a ten- 
dency to bleed, hence the term "bleeder" is applied to this class of cases. 
Whole families are found in which this tendency to bleed exists. 

Pathology. — The walls of the blood-vessels show no alteration, either 
macroscopically or microscopically. "The swelling of the joints is due to 
haemorrhages into the articulations and into the surrounding tissues The 



710 DISEASES OF THE BLOOD. 

tissues are blanched from loss of blood." The surface of the body shows 
petechia or bruised patches. 

Symptoms.- — The appearance of the child does not always disclose the 
tendency to bleed. It is only when an operation is performed, or an in- 
jury exists, that alarming and frequently fatal haemorrhages are seen. 
Epistaxis is the most common symptom noted. Swelling of the joints 
resembling rheumatism is frequently seen. The bleeding takes place 
from the capillaries, most often an oozing which may continue for weeks. 
The subjects of haemophilia are sensitive to cold. 

In the chapter on "Syphilis" I have already described a case of bleed- 
ing in which the lesions of syphilis were present. 

Annie G., 13 years old, was breast-fed in infancy. She had diphtheria when 
1 year old. Had pertussis when 2 years old, which lasted nine weeks. Has had 
pneumonia twice. No history of rheumatism given and has had no other infectious 
disease. 

History of Bleeding. — Has always been troubled with haemorrhages. The nose 
bleeds at the slightest provocation. Blood spitting is quite common. The slightest 
irritation of the bowels with looseness is associated with blood in the stools. Large 
varicose veins are found over the legs. There are a number of scattered naevi. Not 
infrequently the veins of the legs bleed daily for a period of twenty or thirty days. 

The Heart. — There is a loud systolic murmur heard in front and behind, and 
transmitted to the side. This endocarditis is a sequela to the attack of diphtheria. 
The child's weight when seen by me was 67 pounds. Stypticin seemed to do more 
good than ergot internally. Hydrastinine hydrochlorate, 1 / 6 grain three times a day, 
seemed to check the bleeding during another attack. When last seen by me the child 
was developing fairly well. 

Prognosis. — This depends on the frequency of the haemorrhages and 
the child's general condition. In 152 cases reported by Grandidier more 
than one-half died before completing the seventh year, and only nineteen 
attained majority. 1 

Treatment. — All operations, no matter how slight, should be avoided 
if possible. Even the extraction of a tooth must be seriously considered, 
owing to the danger of bleeding. 

The diet should consist principally of vegetables and fruits. When 
bleeding occurs, immediate treatment, consisting of ice and MonselPs solu- 
tion, should be used locally. Internally, gallic acid and hydrastine, % 
grain, repeated every three or four hours. If intestinal haemorrhage exists, 
colon flushings of iced water, temperature of 50° F., containing 1 drachm 
of alum to 1 pint of water, may be tried. An injection of 15 to 25 cubic 
centimeters human blood serum is an excellent haemostatic. If this cannot 
be secured then an injection of 15 to 30 cubic centimeters of sterile horse 
serum may be given. In the case of a ff bleeder," recently seen by me in 
the Babies' Wards of the Sydenham Hospital, one injection of horse serum 
controlled the haemorrhage due to a paracentesis, after all local means failed. 

1 See article in "Starr's Textbook." 



CHAPTER IV. 
DISEASES OF THE GLANDS OR LYMPH NODES. 

The Thymus Gland. 

This long lobulated gland is similar in structure to the salivary glands. 
It lies in the anterior mediastinum, immediately behind the manubrium 
of the sternum. The thymus reaches its full development during the second 
year, after which it gradually disappears. The function of the thymus is 
still a question, although it is believed to have a function similar to the 
spleen. Sudden death has frequently been attributed to an enlarged thy- 
mus. Tuberculosis involving the thymus gland is occasionally seen in cur- 
rent literature. 

Status Lymphaticus. 

This condition is found in rachitic children, and is of especial interest 
because of the enlarged glands at the angle of the jaw in addition to the 
adenoids in the vault of the pharynx, and enlargement of the lingual tonsil. 

The cervical, bronchial, axillary, or the inguinal glands are enlarged. 
There is also a tendency to swelling of the parts. Enlarged lymph nodes 
at the angle of the jaw and hyperplasia of the connective tissue of the nose 
and pharynx are seen. 

The thymus gland is very much swollen, and this is believed to be the 
cause of sudden death in many cases. 

Escherich believes that the pathological condition of the thymus gland 
causes a form of acute intoxication resulting in cardiac syncope and paral- 
ysis. This condition must not be confounded with scrofulosis. 

Escherich has reported a case in which laryngeal spasm occurred thirty 
times a day. In such cases the danger of asphyxia should be borne in mind. 
The condition is of importance because of the danger involved during the 
administration of an anaesthetic. 

The following case was seen by me in consultation with Dr. A. W. 
Newfield during the summer of 1904 : — 

The infant was breast-fed, but did not seem to nurse well. The lymph nodes at 
the angle of the jaw, the groin, axilla, and various portions of the scalp could be 
plainly felt. The child had laryngeal spasms. Had had as many as twenty-five or 
thirty attacks of laryngismus stridulus. The adenoid tissue at the base of the 
tongue was enlarged. There was also a mass of adenoids in the posterior nares. 
The posterior pharyngeal wall was studded with fungous granulations. The infant 
had a very short, thick neck. < The nurse in charge was always afraid the infant 
would die during these spasms. It was necessary to gavage to sustain life. By 

(711) 



712 DISEASES OF THE GLANDS OR LYMPH NODES. 

pumping some of the breast-milk and using cows' milk for alternate feedings we 
gradually strengthened the infant. 

Codliver-oil inunctions were ordered to aid in the nutrition of the body. 

When such a condition is found, great care must be exercised so as not 
to lower the vitality of the patient, but rather to stimulate nutrition by 
giving arsenic in the form of Fowler's solution in addition to iodide of 
sodium. 

Diseases of the Thymus Gland. 

In rare instances the thymus gland may persist until the twentieth year 
or even later in life. When such a condition exists, mechanical pressure has 
caused dyspnoea of a serious nature. Asthma has been reported by some 
clinicians in which an enlarged thymus was found; hence the term "thymic 
asthma." Sudden death has occasionally been caused by an enlarged thy- 
mus. This has been especially noted in children with rickets. Abscesses 
have been reported in the thymus by Dubois. Syphilis and tuberculosis 
have rarely been found. 

Eeich says: "The absolute dullness of the thymus, as determined by 
light percussion, is irregularly triangular in outline, the base being made 
by the outline connecting the two sterno-clavicular articulations, the blunt 
apex situated at the level of the second rib or slightly below it, and the 
sides a little beyond the edges of the sternum. The larger half of this 
triangle of dullness usually falls to the left side. When the limits of dull- 
ness, as given above, vary by one or more centimeters, or obscure the pul- 
monary resonance between the upper line of cardiac dullness and the lower 
lateral limits of thymus dullness, an enlargement of the thymus is probable. 
The thymus dullness is present until the end of the fifth year, after which 
it is inconstant." 

Diagnosis. — The diagnosis of diseases of the thymus gland is frequently 
impossible. An infiltration or swelling of the area surrounded by the thy- 
mus gives rise to symptoms of dyspnoea, from pressure upon the pneumo- 
gastric nerve. The same symptoms are also found when the thymus itself 
is enlarged. When the lymph glands in the anterior mediastinum are 
swollen, dullness on percussion is rare unless there is a cheesy infiltration 
of the lymph glands, according to Eeich. 

Treatment. — Symptomatic treatment only should be instituted. The 
iodide of sodium in very large doses may be tried. 

Acute Adenitis. 

This inflammatory condition of the lymphatics is quite common. It 
is usually caused by an infection, or an abrasion of the skin, permitting an 
infection in or about the glands affected. 



ADENITIS. 713 

The cervical glands are most frequently affected. 

Inflammatory conditions in the nose, throat, the mouth, or on the 
skin give rise to these swellings. 

The axillary glands are frequently swollen, due to septic absorption 
following vaccination. 

The glands of the thigh and the inguinal glands are commonly affected 
when there are irritations or inflammatory lesions involving the genitals, 
or the lower extremities. 

Pathology. — The glands show swelling and infiltration with inflam- 
matory products. The immediate tissues are usually involved. Very fre- 
quently the swollen glands resolve. At other times there is an excessive 
migration of white cells so that the glands break down and abscess results. 

Symptoms. — The glands per se may show inflammatory symptoms, such 
as fever, tenderness, and swelling. It is wise to examine the adjacent parts 
to be sure that the glands are not a secondary inflammatory condition. For 
example, in diphtheria the neighboring glands are usually swollen. If the 
gland only is involved, we have no evidence of reddening or inflammation. 
When inflammation exists involving the neighboring tissues, a reddening 
of the skin takes place. Such cases usually have fluctuations, or soft areas 
can be made out. The glands are swollen, at times reaching the size of a 
hen's egg. 

The diagnosis is very easily made. 

The prognosis depends on the condition of the child at the time of 
infection. If tuberculosis exists, the prognosis is bad. The prognosis of 
acute adenitis in conjunction with acute exanthemata is usually good. 

Treatment. — (a) Abortive; (b) surgical 

Abortive. — The inunction of Crede ointment has served me very well. 
A piece of the salve about the size of a bean should be well rubbed into 
the swollen gland. The rubbing should be continued at least ten minutes. 
Sometimes a leech applied to a gland will reduce the swelling. An ice-bag 
will reduce swelling and sometimes prevent suppuration. Belladonna oint- 
ment and ichthyol, 10 per cent., with lanoline is sometimes useful. 

Surgical Treatment. — When fluctuation is felt, hot fomentations with 
flaxseed meal will be very grateful. An incision should be made, with 
aseptic detail, pus evacuated, and the wound packed with iodoform gauze. 

Later restorative treatment, such as malt, iron, codliver-oil, or the 
syrup of the iodide of iron, should be given. 

Chronic Adenitis. 

Not infrequently we meet with children who have swollen glands last- 
ing months and years in whom no evidence of tuberculosis or syphilid 
exists. 



714 DISEASES OF THE GLANDS OR LYMPH NODES. 

This is usually due to repeated attacks of inflammation following 
acute adenitis, or it is the result of chronic inflammation of the skin. 

Pathology. — The glands show an increase in their cellular and con- 
nective-tissue elements. They undergo a true hyperplasia. 

Symptoms. — The symptoms consist in a swelling of the glands without 
inflammation or tenderness. In chronic adenitis the glands do not break 
down; hence suppuration is absent. In conjunction with chronic enlarged 
glands, we find hyperplasia of the tonsils, so that we invariably have en- 
larged tonsils and adenoids' in such conditions. 

Diagnosis. — The diagnosis should be made after syphilis, tuberculosis, 
and other infections, such as diphtheria and scarlet fever, have been ex- 
cluded, so that we can be sure no specific or infectious disease is the origin 
of the trouble. 

The prognosis is usually very good. 

Treatment. — The treatment consists in removing the cause. Middle- 
ear inflammation, scalp disease, and pediculosis should be vigorously treated. 
Adenoids and diseased tonsils should be removed. Thus the treatment is 
narrowed down to removing the cause if possible and relying on restorative 
treatment, fresh air, and good nutrition. 

Tubercular Adenitis. 

This condition is due to an invasion of the tubercle bacillus, resulting 
in a tubercular manifestation of the glands. It was formerly believed to 
be "scrofulosis." The pharynx and tonsils seem to be the point of entrance, 
as the glands in the cervical region are usually affected. 

Pathology. — The glands undergo a caseous degeneration which fre- 
quently results in abscess. At times we meet with tubercular lesions in 
various organs of the body. In the glands we note that they are studded 
with miliary tubercles and also find the tubercle bacillus therein. 

Symptoms. — The glands enlarge in various parts of the body; most 
frequently the cervical glands are affected. It is usually a very slow process, 
extending over months; sometimes years. During this time, from the long- 
continued inflammation, evidence of a continued illness is shown. When 
these abscesses form they heal very slowly and frequently leave sinuses or 
ragged scars. 

Henry G., 2% years old, was brought to my children's service with a history 
of recurring swelling on both sides of the neck and also behind the ear. The child 
was bottle-fed during infancy and had always suffered with dyspeptic trouble and 
constipation. He has had furunculosis of the scalp, which necessitated incisions, 
during the second year. Was troubled with tonsillar and catarrhal trouble; also 
double otitis. 

The glands of the neck are swollen and frequently break down and discharge 
pus. The temperature is not elevated. This suppuration is known as the cold abscess 
type. The general condition is fair. The child is taking maltine with hypophos- 



TUBERCULAR ADENITIS. 



715 



phites. A restorative diet of cereals, cream, butter, eggs, etc., is given. Attention to 
hygiene and out-door life is the most important part of the treatment. 

Diagnosis. — This can easily be made when we consider the character 
of the glandular swelling, their tendency to caseation, and to suppuration. 
When the pus is examined, tubercle bacilli are invariably found. 

Differential Diagnosis. — In the beginning this disease is difficult to 
diagnose. We can exclude syphilis by the history of the parents. When 




Fig. 228. — Case of Cervical Adenitis in which a Positive von Pirquet 
Reaction Appeared. (Original.) 



the history is not obtainable, resorting to anti-syphilitic treatment will 
materially aid in eliminating the diagnosis of syphilis. In Hodgkin's dis- 
ease the glands do not suppurate. In simple chronic adenitis there is no 
suppuration. 

Treatment. — Attention to hygienic details is of prime importance. 
The diet should consist of restorative foods in which proteins and fats 
abound. Eestorative medication, such as iron, codliver-oil, iodide of sodium, 
and arsenic, and syrup of iodide of iron are the most useful drugs to be 
considered. 



716 DISEASES OF THE GLANDS OR LYMPH NODES. 

Read also the treatment outlined in the chapter on "Acute Miliary 
Tuberculosis." 

The surgical treatment of tubercular adenitis should consist in the 
total removal of the suppurating glands, using aseptic precaution, rather 
than to rely on slow spontaneous evacuation of pus by Nature. 

Mumps (Specific Parotitis). 

This is a specific febrile disease, characterized by inflammation of the 
salivary glands. 

Etiology. — This disease is prevalent all over the world, occurring 
usually in the form of local epidemics. It is more marked during the cold 
and wet seasons than in the summer. Children between 10 and 15 years 
of age suffer most. Boys are more liable to be attacked than girls. Infantile 
parotitis is frequently met with. The nursing infant is not exempt from 
this condition. 

The period of incubation, counting from the exposure to infection 
and the appearance of the disease, varies from fourteen to twenty-five days. 
It is usually about three weeks. 

In New York City, children suffering from mumps are excluded from 
school until the swelling has entirely subsided. Children of the family who 
have not had the disease are excluded until the medical inspector recom- 
mends re-admission. Children in the family who have had the disease may 
remain in school. 

Hoiv the 'Disease is Spread. — Contact seems to .be the method of con- 
veying the disease from person to person. School children and families 
are thus infected. 

Pathology. — The disease is most likely due to an infection by a micro- 
organism. The salivary glands are probably the seat of invasion. 

Symptoms and Diagnosis. — The disease begins with fever lasting two 
or three days. The temperature may reach 104° F., although the usual tem- 
perature is about 101° F. The fever may be so pronounced that delirium 
accompanies the same. The most pronounced symptom is pain and ten- 
derness in one parotid gland. The gland becomes swollen. The swelling 
occupies the space behind the angle of the jaw and below the ear, spreading 
forward on the cheek, and downward along the neck. The edge is ill de- 
fined, and the swelling itself is doughy to the touch. 

Goodhart has reported cases in which the swelling was severe and the 
patient breathed with his mouth open. In such instances the tongue is dry 
and brown, but no serious import should be given thereto. 

The swelling is confined to that portion of the neck between the jaw 
and the sterno-cleido-mastoid muscle. The center of the swelling is im- 
mediately under the lobe of the ear. 



MUMPS. 717 

The swelling becomes so extreme and the pain so acute that the patient 
can hardly do more than separate the upper and lower jaw. The submax- 
illary gland on the same side becomes affected within a day or two and there 
is a large swelling below the jaw. Soon afterward the opposite parotid 
and submaxillary glands may also become involved. Goodhart states that 
a swelling of the cervical lymphatic glands may be the only local signs of 
mumps. 

There is usually a general malaise. The swelling lasts four or five 
days and then subsides. Suppuration never results. The amount of saliva 
secreted is not lessened. In many cases it may be excessive. 

Differential Diagnosis. — The glandular swelling in mumps has fre- 
quently been mistaken for diphtheria. In the latter disease thje parotid 
glands are not affected. The patient rarely encounters difficulty in opening 
the mouth, even when the cervical lymph glands are enlarged. 

The differential diagnosis between mumps and diphtheria must be 
made by a careful inspection of the fauces and tonsils and noting the ab- 
sence or presence of membrane. 

There are other conditions which may be accompanied by parotitis. 
In enteric and other fevers in various disorders of the abdominal cavity, 
one or both parotids may be inflamed. In these conditions, however, sup- 
puration of the parotid gland may ensue. 

Prognosis. — This is almost always favorable. Goodal and Washbourn 
state that during ten years in England and Wales there were but eighty 
deaths registered among the entire population. These authors suspect 
diphtheria as the cause of most of these deaths, reported as mumps. 

Complications. — The most disagreeable complication is orchitis. This 
usually commences when the disease has progressed several weeks. It is 
accompanied by fever, sometimes chills. The body of the testicle and not 
the epidermis is involved. As a rule ice-bags or leeches aided by rest will 
relieve this condition. The attack usually lasts several days, but may be 
prolonged several weeks. 

Treatment. — Local: Hot fomentations, consisting of ground flaxseed 
meal to which a few drops of laudanum have been added, are very grateful 
and well borne. They are to be applied between two thicknesses of cheese- 
cloth. These poultices should be renewed at intervals of one-half hour. 
Among the newer local remedies, antiphlogistine, warmed and applied in 
the form of a salve, has been advocated. 

The occasional application of a leech at the site of the swollen parotid 
will be found advantageous in some instances. 

An ice-bag can sometimes be used to advantage. The local application 
of tincture of iodine can be recommended. 



718 DISEASES OF THE GLANDS OR LYMPH NODES. 

The inunction of: — 

I£ Unguentum belladonna 6 drachms 

Unguentum hydrarg. ciner 3 drachms 

M. Ft. ungt. 

To be rubbed in swollen glands every three or four hours, may be tried. 

Another drug which is quite serviceable is ichthyol, to be applied sev- 
eral times a day, in the following manner: — 

Ifc Ammonium sulpho. ichthyol 2 drachms 

Lanoline 1 ounce 

M. Ft. unguentum. 

To be thoroughly rubbed in swollen glands. 

The local application of a 5 per cent, iodoform collodion painted over 
the inflamed region, several times a day, or a 10 per cent, salicylic collodion 
applied several times a day is at times beneficial. 

The inunction of a 15 per cent, iodide, of potassium ointment will be 
indicated if there is a suspicion of syphilis in the case. ' 

Constitutional Treatment. — Earely do we require internal medication 
in this disease. If, however, there is high fever, sponging the surface of 
the body or cold packs are indicated. The internal administration of a mild 
laxative, such as citrate of magnesia, is grateful and beneficial. 

Five-grain tablets of rhubarb and magnesia will be required if consti- 
pation exists. 

Owing to the infectious nature of this disease, the first rule should be 
to isolate. The isolation should be thorough and continued at least ten 
days from the beginning of the illness. 



CHAPTEE V. 

DISEASES OF THE DUCTLESS GLANDS. 

Cretinism (Myxedematous Idiocy — Myxedema). 

Cretinism is a form of idiocy associated with pachydermatous 
cachexia. 

Etiology. — In my own cases psychical disturbances in the mother 
seemed to result in cretinism. Worriment and fright seemed to have some 
etiological relationship to the development of myxedematous idiocy. 

In two cases of mine the mother suffered with mental depression, con- 
stant worry, and hysterical symptoms during pregnancy. 

Pathology. — We are indebted to Fletcher Beach for a series of careful 
post-mortem investigations which have thrown considerable light on the 
nature of this disease. We know that cretinism is due to the absence of 
the internal secretion of the thyroid gland. In some instances the gland 
is congenitally absent. This condition also results when the thyroid gland 
is removed by surgical means. It is safe, therefore, to assume that the loss 
of the function of the thyroid gland causes cretinism. 

Holt believes that cretinism is in some instances associated with goiter. 
This disease occurs sporadically in our country. 

Symptoms. — The characteristic manifestations are very apparent dur- 
ing the first year of a child's life. Sometimes distinct evidences of cretinism 
can be seen as early as the third month after birth. The child is short in 
stature and light in weight compared to the normal infant. The extremi- 
ties, particularly the fingers, are short and thick. The lips are thick. The 
tongue is broad and thick, and constantly protrudes from the mouth. The 
fontanel is late in closing. The nose is broad, flat, and upturned. The 
nostrils are wide open. The hair is coarse and straight (straw-like). Den- 
tition is delayed, and when the teeth do appear they are very poorly formed. 
The skin of the entire body is thick and dry, but does not pit on pressure. 

The infant is stupid, and it is very noticeable that we are dealing with 
deficient mental development. 

In the supra-clavicular regions there are regularly formed pads of fatty 
tissue, so that the neck is short and thick (Tuttle). The thyroid gland 
cannot be felt unless it contains a tumor. The abdomen is large and 
prominent and an umbilical hernia is frequently present. 

Constipation of a very obstinate character is usually met with and 
persists for a long time. The temperature is subnormal. The thyroid gland 

(719) 



720 DISEASES OF THE DUCTLESS GLANDS. 

is absent or cannot be felt. In palpating the thyroid region we can feel the 
trachea. In some cases there is a hypertrophied hypothenar eminence on 
the palms of the hands. The face in all cases has the prognathous expres- 
sion (Koplik). 

Diagnosis. — The value of an early diagnosis in this condition is more 
important than in any other disease with which we are brought in contact. 
The diagnosis can usually be confirmed after a short period of thyroid treat- 
ment. The specific results of treatment are more apparent in this condi- 
tion than in any other infantile derangement with which we are con- 
fronted. 

Case I. — Frances P. 1 was referred to me by Dr. L. F. Haas. She was the 
seventh child of this family. All the other children were perfectly normal. The 
labor was normal. The child was born before the doctor arrived. 

Family History. — The father is healthy. The mother is strong and healthy. 
During the pregnancy the mother constantly cried on account of family trouble. 
Her husband was out of work. The mother frequently had hysterics. Similar 
psychical disturbances were never present while pregnant with the six other children, 
who are all strong and healthy* 

History Given by the Mother. — The mother noticed that the child had short 
limbs. That she was not bright mentally. That when 1 1 / 2 years old she could 
neither walk, talk, nor support her head. The tongue was very thick and protruded 
almost constantly while awake, as well as when asleep. The hair did not grow. 
The nose was short and flattened. The skin was yellowish and dry. The child had 
a jaundiced appearance. Constipation since birth. The bowels were moved with 
difficulty. The infant was breast-fed until it was fifteen months old. Up to this 
time there was no sign of dentition. She was taken to the Babies' Hospital, 
which necessitated her being weaned from the breast. She remained in the 
hospital about two weeks. When sixteen months old, one month after thyroid 
treatment was commenced, the first tooth appeared. The child was successfully 
vaccinated at the end of the first year. 

During its first year and up to the time that it was taken to the hospital, it 
did not suffer with any infectious disease. 

My first examination was on December 8, 1902. The child at that time was 
2 years, 2 months old. The following conditions were found: — 

The child can neither walk nor talk. The tongue is very thick and protrudes 
constantly. The lips, the eyelids, and the skin of the face are thickened, coarse, and 
rough. The nose is short and flat. The skin has a yellowish jaundiced appearance. 
The fontanel is widely open both anteriorly and posteriorly. The face is broad and 
the eyes are set very wide apart. There is a marked depression on each side of the 
temporal bone. There is a marked frontal protuberance. The child had nine 
teeth when twenty-two months old. As previously stated the first tooth appeared 
one month after the thyroid treatment was commenced, or when the child was 
sixteen months old. The body is well developed — fat. There is no evidence of 
rachitis. The chest and spine show evidences of good nutrition. The length of the 
body was 50 a / 2 centimeters, or about 20 inches. The secretions of the body were 
very torpid. Constipation of a very obstinate form was encountered. There were 
several fatty growths in the sterno-cleido-mastoid muscle. 

1 Three cases of cretinism were presented by me at the Section of Pediatrics 
of the New York Academy of Medicine, February 11, 1904. 



CRETINISM. 



721 



Sporadic Cretinism. 

Fig. 229.— Child. Age 2 
years, 2 months. (Origi- 
nal.) 



Fig. 230. — Same child. Seven 
months after continued thy- 
roid treatment. ( Original. ) 

Fig. 231. — Same child. Age 
3 years, 9 months. One 
year and seven months 
after continued thyroid 
treatment. (Original.) 




Fig. 229. 




Fig. 230. 



Fig. 231. 



46 



722 



DISEASES OF THE DUCTLESS GLANDS. 



The child had a -violent fear of water, so much so that the mother had difficulty 
in bathing her. The hair is very thick and straw-like. The thyroid gland cannot 
be felt. 

The pulse was 90 and of a full bounding character. There was a subnormal 
temperature which was never higher than 98° F. in the rectum in the evening. 
Respiration was 16 while quiet and 24 while crying. The urine showed traces of 
indican, evidently due to the constipation. No albumin or sugar was found. Micro- 
scopically no uric acid crystals; no casts, and no bacteria were found. 

When the treatment was first commenced, 1 grain of thyroid was given three 
times a day. This dose was rapidly increased so that after the first week the child 
took 2 a / 2 grains three times a day. The heart was carefully watched and no 
disturbance noted from the quantity of thyroid given. In addition, 10 drops of 
pure codliver-oil was given three times a day. Cereals, milk, chicken soup, broths, 
and acid fruits, such as oranges, lemons, and cranberries, were ordered. Fresh air and 
bathing, with vigorous friction, concluded the hygienic treatment. Under this 
vigorous treatment the child developed very fast. The length of the body was 
58 V a centimeters at the end of the first month of this treatment. The growth, 
therefore, in one month amounted to 8 centimeters or S 1 / s inches. The obstinate 
constipation was improved and the bowels became regular. The teeth have 
appeared at regular intervals. The facial expression has changed. The child now 
commences to walk, as also to talk, she says "mamma" and "papa." 

The fear of water and to be bathed is past. She no longer cries when she sees 
water. At the end of 1 year, the length of her body is 85 centimeters or 33 V a 
inches, so that she has grown in 1 year 34% centimeters or 13% inches. 

The child is still taking thyroid and is progressing favorably. 



Table No. 74. — Length and Growth of Body. 



Age. 



Length of Boiy. 



Gain in Growth of Body. 



2 yrs. and 2 mos. 

2 yrs. and 3 mos. 

3 yrs. and 3 mos. 



50J centimeters (19}f inches) 
58 J centimeters (23 T ^ inches) 
85. centimeters (33 J inches) 



1 mo., 8 centimeters (3£ inches) 
12 mos., 34 \ centimeters (13J inches) 



Case II. — Rosie H., born January 1, 1902, now over 2 years old, was first seen 
by me when she was eighteen months old. 

Family History. — Father living, is somewhat dyspeptic. Has no specific disease. 
The mother is a very nervous woman, otherwise in good health. This is her first 
child. She has had one other pregnancy of eight months which was still-born, 
believed to have been an asphyxia neonatorum. No miscarriages. No lues. 

Child's History. — She was breast-fed for seven months, later she received equal 
parts of milk and water. When first seen by me at the age of eighteen months, she 
was still fed on equal parts of milk and water. There has always been severe 
constipation, and streaks of blood have frequently been seen in the stool from severe 
tenesmus. The examination of the child at that time showed coarse, sparse hair, 
and a very rough skin. The tongue and the lips were very thick. The tongue 
always protruded from the mouth; breathing was difficult. There was constant 
snoring, and the mouth was always open. The thorax was decidedly rachitic ; there 
was a funnel-shaped depression, and also a kyphosis and an umbilicated hernia. The 
child could neither stand nor talk. There was no evidence of teething. The appetite 
was poor. The temperature was subnormal, 98 2 / 6 ° in the rectum. The pulse was 



CRETINISM. 



723 







H^^ ^^B 




Sporadic Cretinism. 








Fig. 232.— Child. Age 1 
year, 5 months. (Origi- 
nal.) 




.*"■- 




Fig. 233. — Same child. Age 
2 years. (Original.) 








Fig. 234. — Same child. Age 
3 years, 5 months. (Orig- 
inal.) 






-^j 






i-W7,N| H^*^^*^ 


1 



Fig. 232. 




Fig. 233. 



Fig. 234. 



724 DISEASES OF THE DUCTLESS GLANDS. 

100, small, and feeble. The heart sounds muffled. A haemic murmur was plainly 
heard at the apex and also in the vessels of the neck. It was impossible to secure 
a specimen of urine for examination. A drop of blood was examined and showed a 
decreased number of red blood-corpuscles and a marked leucocytosis. The diagnosis 
made was sporadic cretinism. The circulation was poor and there was a slight 
oedema constantly present. The feet and hands were frequently cyanotic, and always 
felt cold. The anterior fontanel was widely open. Growth was stunted as the 
length of the body was only 55 centimeters. .The naked weight when 1 1 / 2 years old 
was 11 pounds 13 ounces. When first seen by me there was neither muscular nor 
bony development which could be considered normal. At eighteen months the child 
had had no teeth. At twenty-two months the first tooth appeared. The muscles of 
the body were limp and flabby. The child could not support her head nor was there 
good support to the spinal column. The patellar reflexes were but slightly present. 

Treatment. — The treatment consisted in giving fresh, raw milk warmed to body 
temperature. In addition to the milk, steak juice, orange juice, potato flour, and 
the usual antiscorbutic remedies were ordered. Fresh albumin, using the raw white 
of egg, and vegetable proteids, such as pea soup and lentil soup, were very well 
assimilated. 

The medicinal treatment consisted of two drugs. Thyroidine was given in doses 
of Va grain three times a day, and gradually increased until 3 grains were given three 
times a day. The other drug was Fowler's solution given in 1 drop doses, increased 
to 3 drops three times a day. It is now about six months since the treatment was 
commenced. The child has grown in length from 55 centimeters to 69 centimeters 
and the weight has increased from 11 pounds 13 ounces to 17 pounds. 

Case III. — Rosie N. was first seen by me on June 28, 1902. She was then 
seventeen months old. 

Family History.— Father is healthy. No family history of tuberculosis, syphilis, 
or any other taint. The mother is in good health and has never had any serious 
illness nor miscarriage. This was her first pregnancy. The mother's condition was 
good, there was no traumatism nor any psychic disturbance. The infant was born 
without the aid of instruments. It was a perfectly normal delivery. The mother 
menstruated while nursing the infant. 

Personal History.— The infant was nursed about sixteen months. She did not 
seem to thrive since she was three months old. Severe constipation had always 
existed, and was present when I first saw her. She could neither stand, walk, nor 
talk. Backwardness in development was very apparent. Spasmus nutans was 
present. The fontanel was widely open. She showed no signs of intelligence. The 
hair was coarse and straight. The extremities were short. The growth stunted. 
She presented a squatty appearance. The skin was rough, thickened, and large 
eczematous patches covered the arms and legs. The child was sent to me by Dr. 
L. Weiss, who had her under his care for the relief of the eczema. The lips were 
thick. The tongue was thick and protruding. She had two lower incisors; no 
other evidence of dentition. The facial expression was senile and corresponded with 
that of a typical cretin. She was restless by day and suffered with insomnia by 
night. The urine was examined and contained no albumin nor sugar. Slight traces 
of indican were seen, microscopically nothing pathological. The blood examination 
showed four million six hundred and twenty thousand (4,620,000) red blood-cor- 
puscles, and seven thousand two hundred (7200) white cells. 

The percentage of haemoglobin taken with Gower's instrument was about 40 
per cent. As digestion was very poor I decided to syphon off the gastric contents 
two hours after a meal and to examine the same chemically. 



CRETINISM. 



725 



Feeding. — The feeding was barley water. About 5 cubic centimeters were 
syphoned off, which showed traces of peptones, starch, and sugar; HC1 was absent 
by Gunzberg's test. I am indebted to Mr. Charles La Wall for his assistance in the 
chemical analyses of the gastric contents, made a number of times. 

Equal parts of milk and barley water were fed every few hours. Thyroid 
treatment was commenced; 1 / 2 grain of the desiccated, powdered thyroids was ordered 




Fig. 235.— Cretinism. Age 7*4 years. 
Height 26% inches. Front view. 



Fig. 236.— Cretinism. Age 7*4 years. 
Height 26% inches. Back view. 



three times a day. The dose was gradually increased and the child now receives 3 
grains three times a day. There was no cardiac disturbance from this dose. 

Lemon juice, orange juice, raw albumin, and vegetable soups were ordered. 
The child's condition improved. The specific effect of the thyroid was very apparent. 

Case IV.- — Gussie S., 1 7 years and 3 months old when she came under my obser- 
vation. She was born January, 1897. She is the oldest of four children. The other 
children are to all appearances healthy, as are also the parents. 



*I regard this case as the most complete type of cretinism that I have ever 
seen. The notes were kindly furnished by Dr. A. E. Isaacs, in whose practice the case 
occurred. 



726 



DISEASES OF THE DUCTLESS GLANDS. 



Family History. — The mother claims to have had a severe fright during her 
sixth month of pregnancy, and attributed the child's mental deficiency to this psych- 
ical disturbance. There is no history of any condition similar to this child's on 




Fig. 237.— Cretinism. Same case. Age 
8 years. Height 33^ inches, gain 6% 
inches. 



Fig. 238.— Cretinism. Same case. Age 
8 years. Height 33^ inches, gain 6%. 
inches. Back view. 



either side of the family. Parents are natives of Russia. They are 13 years in this 
country, and do not know of any such disease in their native country. The parents 
are not related. 

Feeding. — The child was breast-fed for about two years. She did not receive 
any other food during this period. When the child was thirteen months old the 
mother's menstruation returned. The mother continued to nurse the child until the 
end of the second year, although she continued to menstruate every month. 

Nothing unusual was noticed about this child until the end of her first year. 
She cried very little and slept a great deal. At about 1 year of age parents noticed 
that she differed from other children of the same age. No teeth appeared. She 



CRETINISM. 



727 



made no attempt to walk or stand. Never laughed or smiled, was always apathetic 
and took no interest in her surroundings. There was no appreciable growth in 
height from 1 to 7 years. The same dresses always fitted her. In her fifth year 
she was for a period of six months very cross and restless, but this disappeared as it 
came, without any known cause. 




Fig. 239.— Cretinism. Same case. Age 
9 years. Height 37% inches, gain ty 2 
inches. Front view. 



Fig. 240.— Cretinism. Same case. Age 
9 years. Height 37% inches, gain W2 
inches. Back view. 



She cut her incisor teeth at 3 years of age and the rest at 4 years. She has 
never had convulsions or any other sickness except measles when 4 years of age. 
She began to stand on her feet with assistance when 3 years old. She did not speak 
a word until 5 years old, from which time till I took charge of her she could say 
no more than "papa" and "mamma." 

When she came under my observation, she was 26 1 / 2 inches high. She weighed 



728 



DISEASES OF THE DUCTLESS GLANDS. 



25 Vs pounds and was quite stout in proportion to her height. Her head was large 
in proportion to her body. The lips were thick. The nose flat and depressed between 
the eyes. The neck was very short. No sign of enlarged thyroid, large blue eyes, 
teeth in fair condition, complexion dark, hair dry and of a rusty black color. 




Fig. 241.— Cretinism. Same case. Age 
11 years. Height 39% inches, gain 2 
inches. Front view. 



Fig. 242.— Cretinism. Same case. Age 
11 years. Height 39% inches, gain 2 
inches. Back view. 



Hearing, sight, and smell apparently good. Voice not out of the ordinary. 
The extremities were short and thick, lower ones were bow-legged. The ends of the 
bones were large. The belly was large and its prominence exaggerated by a decided 
anterior curvature of the spine. Intelligence was almost nil, temperament very 



CRETINISM. 729 

irritable, does not cry, but becomes very angry. She never asks for food, eats little 
and only what is given to her. The bowels were constipated, moving only once in 
two days. She never asks to pass stool or water. Had external haemorrhoids, which 
bled occasionally. When awake was constantly sitting. Cannot walk alone and 
only a few steps when assisted. She slept well. Pulse was 96 and regular. 

Has had no treatment for three years. Previous to this time parents had been 
all over with her and tried everything suggested, without avail. 

On January 25, 1897, I put her on 3 grains, once a day, of desiccated thyroids 
(Parke, Davis & Co.). On February 18th dose was increased to 4 grains daily, but 
after a week the dose had to be reduced to 2 grains, as the pulse rose to 120 and the 
child became irritable. Otherwise, some improvement was already noted in her 
general condition ; she could stand better and moved her bowels daily. After another 
week (March 6th) the dose was increased again to 3 grains daily and was continued 
so till I saw her on March 21st, when I found her pulse 144, strong and bounding. 
She had become considerably thinner, having lost 1 7 2 pounds in weight in spite of 
the fact that she had gained 2 inches in height. This gave her a much more natural 
appearance. She also had a more intelligent facial expression, talked more and 
decidedly better, walked a short distance without assistance, and ate better. 

On account of the accelerated pulse and loss of flesh, I decreased the thyroids 
again to 2 grains daily. From this time on there Avas a gradual improvement in all 
the symptoms. By the middle of April she was running about the streets, playing 
with other children, and asked for her food. In May she began to tell when she 
w T anted to move her bowels, gradually gained in intelligence, spoke more and articu- 
lated better. The dose of the thyroids was gradually increased until she was taking 
5 grains daily (July), which she continued for more than a year and a half without 
any symptoms of intoxication. 

I had the honor of presenting her before the Society 1 in 1898 after one year's 
treatment, when she had gained 6 3 / 4 inches in height. The privilege was accorded 
me again in 1899 when she had gained an additional 4 V 2 inches. The average growth 
of a normal child of her age is less than 2 inches a year. She had gained over 
eleven (11) inches in two years. 

As interesting as this case is so far, the most significant and interesting part of 
it comes now. I lost track of the patient in January, 1899, and she took no medicine 
from that time until I saw her again in December, almost a year later. My note- 
book records the fact that there was no increase in height and that her general 
appearance was not good. Although I ordered the thyroid extract it was not given 
again until I saw the patient one-half year later, on June 1st, 1900, and again there 
was no increase in height or improvement in general condition. The patient's next 
visit was in February, 1901, when she reported that 5 grains of the thyroid had been 
given daily from June 1st to December 24th. Measurement showed a gain of 2 inches 
in height (39 1 / 2 ). Her general appearance was much better and she had been goipg 
to school for a few weeks. 

If any proof be necessary as to the efficacy of the thyroid principle in cretinism, 
or as to the thyroid gland and its secretion being essential to the proper physiological 
workings of the human body, the history of this case supplies it. Take the one 
symptom of stature. From 1 to 7 years of age, without the administration of 
thyroids, there was no increase. From 7 to 8 years, with thyroids, there was a 
growth of 6 3 A inches. From 8 to 9 years, also with thyroids, there was a growth of 
4 V 4 inches. From 9 to 10 years, without any thyroids, there was no growth. From 



1 Eastern Medical Society, New York City. 



730 DISEASES OF THE DUCTLESS GLANDS. 

10 V2 to 11 years, with thyroids again, 2 inches were gained. All other manifesta- 
tions of this cretinic condition underwent corresponding fluctuations with the ad- 
ministration of the extract, but changes in stature being the most evident, serve 
best to illustrate the progress of the case. 

To contrast her previous with her present condition as well as to show her 
appearance during the period of her improvement no better means could be utilized 
than the accompanying photos. The first pair was taken in February, 1897, the 
second in 1898, the third in 1899, and the fourth in February, 1901. 

She is now sufficiently intelligent to go to school. She plays as a child should 
and her general health is very good. She has yet the physical marks of her previous 
condition in the peculiar features, the short neck, and the spinal curvature with 
the abdominal prominence, though they have all improved, especially the spine and the 
abdomen. Her height is about 12 inches short of what it should be at her age, 11 
years, but if the rapid rate of growth continues she will gain a good part of it. 

September, 1901. — Has taken little medicine. Height about the same. 

April 27, 1902. — Has taken medicine one and one-half months since last visit. 
Height, 41 V4 inches; goes to school. 

September 4, 1902. — Has taken 5 grains daily since April 27th. Looking and 
feeling well. Losing flesh, feels cold at night, hands tremble when taking things to 
mouth since six weeks. Pulse, 188. Height, 41 1 / 2 inches. Discontinued thyroids 
three weeks. 

I saw case on December 20^ 1902. No thyroids since last week. Patient is 
gaining flesh, shivering (trembling) stopped. Pulse, 72. Goes to school, has 
mastered her figures only (is almost 13 years old). Ordered 2 1 / 2 grains thyroid 
daily. 

When last seen, April 20, 1904, the mother stated the girl had been going to 
school for the last two years. Very little mental progress has been made during this 
time. She reads an elementary primer and can remember figures. Has taken thyroid 
but four months out of the last sixteen months. Her height is 43 a / 4 inches. She 
has- gained in the last sixteen months about two inches. Her pulse-rate is 72. 

Prognosis and Course. — The sooner treatment is instituted the better 
the result. When this condition is neglected, children become worse and 
worse until finally they are beyond medical aid. 

It must be borne in mind that thyroid must be given for years if last- 
ing results are to be obtained. Children will go backward at once if we 
discontinue our treatment, even though the same has been continued for 
some years. An interesting study is the continuous growth including men- 
tal development plainly seen in the illustrations of cases in this chapter. 

Treatment. — The most important part of the treatment consists in 
administering from 1 to 5 grains of the dessiccated extract of thyroid. 
This replaces the active principle of the normal thyroid gland. I have 
used with very good success thyroidin, from 1 / 2 to 2 grains three times a 
day, with equally good result. 

Great care should be taken to watch the pulse-rate while giving thy- 
roid. The pulse will sometimes increase from twenty to forty beats after 
the administration of 1 or 2 grains of thyroid. The moment we find an 
exaggerated pulse-rate, it will be necessary to reduce the dose of thyroid 



EXOPHTHALMIC GOITER. 73 ± 

at least one-half. A flabby, fat child will at once lose weight, and an impor- 
tant feature of successful treatment is an increase in height. 

Thyroid Implantation. — Implantation of sheep's or lamb's thyroid 
(heterogeneous), or from the human being (homothyroid), has been advo- 
cated by some. In one case of mine, operated by Dr. Howard Lilienthal, 
the implantation of lamb's thyroid was tried. Several pieces were im- 
planted in the peritoneal cavity. Some improvement was noted. 

We must not, however, blindfold ourselves to the belief that when we 
supply the missing internal secretion, namely, thyroid, that we have ful- 
filled all indications. 

The diet must be regulated and the child given a large portion of pro- 
teids — milk, meat or meat extracts, fresh beef blood or roast beef juice, 
orange juice, fresh eggs, and all cereals must be given as body builders. 
Fresh air and a general attention to the t^gienic condition of the child are 
very important. Massage, gymnastics, and exercise should not be over- 
looked. 

If the appetite is poor 1 to 2-minim doses of the tincture of nux vomica 
will do good. Butter and codliver-oil are valuable adjuncts. 

Exophthalmic Goiter ( H yperthyrea, Basedow's Disease, 
Graves's Disease). 

This disease has occasionally been seen in children. It is supposed to 
be due to a hypersecretion of the thyroid gland. Sachs believes that hered- 
ity is a more important factor than excitement or fright. Epileptic and 
alcoholic parents certainly predispose to this condition in children. 

Symptoms and Diagnosis. — There are three symptoms of importance 
which should be noted : — 

1. The enlargement of the thyroid. 

2. Palpitation of the heart (tachycardia). 

3. Protrusion of the eyeballs (exophthalmus). 

The blood tension is increased, hence haemorrhages from the nose, 
stomach, or intestines are quite common. Disturbances of vision due to the 
exophthalmus are never described. The thyroid enlargement is usually 
bilateral. Muscular tremors are also noted. The diagnosis is easily made by 
recognizing the symptoms above described. There is a physiological hyper- 
emia of the thyroid which is entirely different from goiter. 

Prognosis. — Cases seen by me have all assumed a chronic tendency. I 
have never known death to occur directly from this condition. When death 
occurred it was due to some complication. 

Treatment. — Spartein sulphate, strophanthus, digitalis or belladonna, 
combined with iodide of sodium may be tried. The galvanic current is 
strongly advised by some writers. Eecently x-ray treatment has been 



732 DISEASES OF THE DUCTLESS GLANDS. 

used in conjunction with the above-mentioned drugs. The danger of 
x-ray dermatitis should be remembered by those -having little experience 
with light treatment. 

The use of thyroid has been suggested, but it has failed to do good in 
my hands. 

Acute Thyroiditis. 

Inflammatory conditions such as abscess have been described as a com- 
plication of the infectious diseases. The migration of streptococci or other 
pyogenic bacteria may give rise to suppurative inflammation. The treat- 
ment is surgical. 

Abnormality of the Thyroid. 

Syphilitic gummata and tuberculosis have been found in rare instances. 
Malignant disease involving the thyroid has been reported among infantile 
disorders. 

Diseases of the Adrenal Glands. 

Pathologists have frequently described haemorrhages into the adrenal 
glands in the new-born infant. Diseases per se, excepting cancer, have not 
been described. There is still considerable to be learned concerning the 
physiology of these glands. 

Addison's Disease. 

This rare condition is occasionally described. Literature records about 
twenty cases in all. 

Symptoms. — The symptoms of the disease consist of a deep-yellowish 
or bronzed pigmentation of the skin. It is found on the. exposed parts of 
the body, such as the hands and head. The mucous membranes of the 
mouth and vagina are also pigmented. White areas of skin are scattered 
over the body. Vomiting, diarrhoea, and nervous symptoms are noted. 
Anaemia is usually very marked. 

Diagnosis. — In the diagnosis of this condition it is necessary to exclude 
pigmentation of the skin due to metallic poisons, such as argyria, from the 
internal administration of nitrate of silver. Arsenic and lead have been 
reported as causative factors of bronzed skin. 

Prognosis. — While most authors report the outcome as fatal, some few 
recoveries have been noted. In a case seen by me recovery took place after 
several years of treatment. 

Treatment. — We have no specific treatment for this condition. Some 
authors advise the administration of the raw or cooked adrenal glands of 
the sheep. The dry extract in tablet form has been isolated and 1-grain 
doses of this extract may be given three times a day. When the gland 
itself is used, one-half to one gland may be given in twenty-four hours. 

The value ,of hygienic and dietetic measures I regard as more impor- 
tant than medication. 



PART IX. 

DISEASES OF THE NERVOUS SYSTEM. 



CHAPTEE I. 

FONTANEL. 



The posterior fontanel is usually closed at the end of the second month. 
The anterior fontanel normally closes between the sixteenth and twentieth 
months. If the fontanel is open at the end of the second year, then rickets 
or other abnormality may be considered. A fullness of the anterior fontanel 
and bulging of the same at the end of the second year is pathological. (See 
chapter on "Hydrocephalus.") Premature closure of the fontanel fre- 
quently occurs in microcephalus and also in congenital idiocy. This prema- 
ture closing interferes with the proper growth and development of the brain. 

Shape of the Head. — Peculiar shapes of the head are met with unde r 
perfectly normal conditions. An interesting study is the series of outline 
sketches of the head which show the modifications in form produced by 
labor and also the normal sketches of the head. 

Circumference. — The average circumference of the head at birth in 446 
full-term infants taken in about. equal numbers from the Sloane Maternity 
Hospital and New York Infant Asylum, quoted by Holt, was as follows : — 

Average circumference of the head, 231 males.. 13.90 inches (35.5 centimeters) 

Average circumference of the head, 251 females 13.52 inches (34.5 centimeters) 

Total 446 infants. 13.71 inches (35.0 centimeters) 

Auscultation of the Anterior Fontanel. — A bruit is occasionally heard 
over the anterior fontanel. (Plates XXXIV, XXXV.) It is a blowing 
sound similar to that heard in the vessels of the neck during anaemia or in 
chlorotic girls. I have described this condition in the chapter on "Kachitis." 

Percussion of the Skull. 

MacEwen, in his treatise upon the pyogenic infective diseases of the 
brain and spinal cord, says : "When the lateral ventricles are distended with 
serous fluid, as would be occasioned by cerebral tumors pressing on the 
fourth ventricle, or by occlusion of the veins of Galen or otherwise, the per- 
cussion note is markedly altered, the resonance being greatly increased. 

(733) 



734 DISEASES OF THE NERVOUS SYSTEM. 

Outline Sketches of the Head, Showing the Various Diameters. 




Fig. 243. — Sagittal Section of 
Normal Head of Seven and One-half 
Months' Foetus, Half Natural Size. 
(After Ballantyne.) 



Fig. 244. — Normal Head as Seen 
from Above, Half Natural Size. 
(After Budin.) 




Fig. 245.— Sagittal Section of Nor- 
mal Head, Half Natural Size. 
(After Budin.) 



Fig. 246. — Sagittal Section of 
Head Immediately After Normal, 
Easy Labor, Half Natural Size. 
(After Ballantyne.) 



Besides the increased resonance, there is an important feature which may be 
demonstrated : The percussion elicited at a given spot on the cranium, such 
as the pterion, varies according to the position of the head. While the per- 
son sits with the head upright, the most resonant note is brought out by 
percussion toward the basal level of the frontal hones and the squamous 



OUTLINE SKETCHES OF THE HEAD. 



735 



Outline Sketches of Head of Infant, Showing the Modifications in 
Form Produced by Labor, etc. 



Fig. 247.— Sagittal Sec- 
tion of Head Immediately 
After Labor (0. D. P. 
Position). (After Bal- 
lantyne. ) 




Fig. 248.— Sagittal Sec- 
tion of Head Immediately 
After Labor, Half Nat- 
ural Size (0. D. P. Posi- 
tion). (After Budin.) 



Fig. 249.— Sagittal Sec- 
tion of Head of Infant Six 
Days Old, Half Natural 
Size. (After Ballantyne.) 




736 DISEASES OF THE NERVOUS SYSTEM. 

portion of the parietal. If the patient hangs his head to one side, so that 
one parietal is placed fairly below the other, the greater resonance is found 
on percussion of the lower parietal. Eeverse the position and the same note 
is elicited on the opposite side of the head, which is now the lower, the 
greater resonance being found at that part of the skull nearest the lateral 
ventricles, and which for the time is at the lowest level. 

"These observations tend to indicate that the quality of this note is 
not dependent on the mere density of the diameter of the cranium, but to 
a large extent upon the consistence or arrangement of the intercranial con- 
tents relatively to the osseous walls. . . . The exact mechanical quality 
of the note is difficult to describe, but, when heard, it conveys the idea of 
hollowness. One such case, in which the above phenomena were clearly 
marked, was observed to a conclusion. The percussion note was not so clear 
at first as it ultimately became, the resonance increasing as the disease 
advanced. 

"In tumors of the cerebellum it is an aid to diagnosis, and when present 
with abscess it points to an involvement of the cerebral fossa." 

The Brain. 1 

In the new-born the dura mater is closely adherent to the skull, so that 
extravasations between the dura mater and the skull are unknown. 

Fluid in the Subarachnoid Space. — In infancy and childhood more 
fluid is found in this space than in adult life. McClellan believes that 
"hydrocephalus due to an excessive amount of fluids in the ventricles of the 
brain may be caused by the closure of a small opening in the pia mater 
which is found at the inferior boundary of the fourth ventricle known as 
the foramen Magendie/'" 

Blood-vessels of the pia mater are so delicate that blood pressure, trau- 
matism, etc., may cause haemorrhage into the subarachnoid space, resulting 
in monoplegia, hemiplegia, or diplegia. 

Growth and Development of the Brain. — From birth until the seventh 
year is reached the brain grows very rapidly; after the seventh year the 
growth is slow. 

Weight of the Brain. — The weight of the brain of the new-born infant 
is one-third that of the adult. In male and female children it is approxi- 
mately the same at birth, although later on the male brain grows more 
rapidly than the female. When a child is between 7 and 8 years of age, 
the brain reaches the adult size and weight. There is from this time on a 
slight increase in the weight up to the twenty-fifth year. 

Vierordt states that the increase of the brain after the seventh year is 



1 The development of the senses is described in Part I, chapter on the "New-born 
Infant." 



PLATE XXXIV 




Front View of the Foetal Skull, showing the anterior fontanelle and the 
coronal and frontal sutures. (Grandin & Jarman. ) 



PLATE XXXV 




Top View of the Foetal Skull, showing the anterior fontanelle and the 
frontal, coronal, and sagittal sutures. (Grandin & Jarman.) 



PLATE XXXVI 



Posterior View of the Foetal Skull, showing the posterior fontanelle and the 
lambdoidal and sagittal sutures. (Grandin & Jarman.) 



REFLEXES. 73 7 

due to an increase in the thickness of the cortex and in the size of the 
cortical constituents. 

Difference Between Infantile and Adult Brain. — The fissure of Sylvius 
in its relation to the spherio-parietal and squamous sutures occupies a 
higher position in childhood than in later life. Symington and McClellan, 
in studying frozen sections of the brain of children under 7 years of age, 
found the Sylvian fissure above the squamous suture and covered by the 
parietal bone. 

Fissure of Rolando. — The position is the same in the infant as in the 
adult. 

The Cerebellum. — This is much smaller in the child than in the adult 
in comparison with the cerebrum. 

The convolutions of tJie orain are more shallow in the infant than in 
the adult. The depressions or sulci between the convolutions are not so 
deep in the infant as in later life.. The special centers of the brain are not 
fully developed in the infant (Taylor and Wells). 

Eeflexes. 

Excess of Reflex Action. — In acute mania, in cerebritis, and in acute 
meningitis we have excessive reflex action. In chronic hemiplegia an in- 
crease of the reflexes associated with ankle clonus is found on the affected 
side. In hydrophobia, transverse myelitis, insular sclerosis, and in tetanus 
we have an exaggeration of superficial and deep reflexes. Attention is 
directed to the chapters On "Tubercular Meningitis" and "Epidemic Cerebro- 
spinal Meningitis" for clinical illustrations of the reflexes. 

Diminution of Reflex Action. — The reflexes are lessened and sometimes 
absent in melancholia. Extreme pressure in the cranial cavity or in the 
spinal canal will reduce the reflex act. "Whenever a degeneration of mus- 
cles or nerves takes place, such as in diphtheria or other specific diseases, the 
reflexes will be lessened. The reflex is reduced or wanting in acute anterior 
poliomyelitis. 

Babinski Reflex. — In the new-born baby this reflex has frequently been 
noted under normal conditions. Instead of normal flexion of the toes, 
which is accomplished by irritation of the soles of the feet, we have in dis- 
ease a hyperextcnsion of the great toe. This symptom is regarded as 
pathognomonic by some authors. I have frequently found- this symptom 
present in tuberculous meningitis, and regarded it as a valuable diagnostic 
aid. (See clinical case, article on "Tubercular Meningitis.") 

Reaction of Degeneration. — "In health a faradic current of sufficient 
strength applied to the nerve produces a continuous contraction of the mus- 
cle ; the galvanic, a momentary contraction when the current is made and 

broken only. When the nerve is diseased a stronger faradic or galvanic 

47 



738 DISEASES OP THE NERVOUS SYSTEM. 

current is needed to produce contraction, until finally, when degeneration 
has taken place, no current which can be used produces any contraction. 
In health either current applied to the muscle produces contraction; the 
response both to the galvanic current and to the faradic is quick, being in 
both instances due to stimulation of the nerve-endings. With lesion of the 
nerve and consequent degeneration of the nerve-endings, the faradic cur- 
rent produces no contraction, but since the galvanic current is capable also 
of stimulating the muscle fibers themselves, a contraction follows appli- 
cation, though more slowly than when the nerve-endings are healthy. After 
the degeneration has progressed to a certain stage, which is reached the 
earlier the more severe the case, this response of the muscle fibers to the 
galvanic current becomes more ready than in health. To this quantitative 
change is added a qualitative change. In health the weakest galvanic cur- 
rent which causes contraction of the muscle does so when the current- is 
made with the negative pole on the muscle (kathode closure contraction, 
K. C. C). When the nervous mechanism has degenerated a contraction 
may occur with as weak or with a weaker current when the positive pole is 
on the muscle (anode closure contraction, A. C. C), and contractions may 
occur also with the same current when it is broken (anode opening contrac- 
tion, A. 0. C, and kathode opening contraction, K. 0. C. 1 ). To this 
altered qualitative and quantitative reaction of nerve and muscle to the 
electric currents the term "reaction of degeneration" is applied. It is not 
always as definitely marked as is above described. When the damage to 
the nerve is slight, the irritability of the nerve to both currents may be 
retained, and the only evidence of the existence of a reaction of degenera- 
tion is increased muscular irritability to the galvanic current, with some 
change also in the order of contraction to the poles (qualitative change). 
On the other hand, in very chronic changes the loss of irritability proceeds 
pari passu in nerve and muscle, and the reaction of degeneration is not to 
be observed. 

"With the regeneration of the nerve, recovery of function takes place, 
the rate of recovery depending mainly on the severity of the lesion. Vol- 
untary power is first regained, then the galvanic reactions become normal, 
and lastly, the faradic. 

"Anaesthesia, which is the eventful result of degeneration of a senscry 
nerve, may be preceded by a condition of hyperesthesia. The anaesthesia is 
often incomplete, especially in the hands and face; in a mixed nerve a 
lesion, capable of producing paralysis of motion, may be accompanied by 
little loss of sensation. Trophic changes seem seldom to occur in children 
as an accompaniment of lesions of sensory nerves." 



■The normal order ie: K.C.C., A.C.C., A.O.C., K.O.C. 



CHAPTEE II. 
CONVULSIONS (ECLAMPSIA). 

Convulsions occur mostly in infancy. After the seventh year of life 
they are very rare. The brain grows more during the first year than in all 
later life. This rapidity of growth is in itself, according to some writers, 
an important predisposing cause of functional derangement. 

Etiology. — The Exciting Causes. — The predisposing causes may be 
grouped under the name of "central." They are : — 

1. Diseases having a high temperature. 

2. Diseases accompanied by vascular stasis. 

3. Diseases characterized by anaemia and exhaustion. 

4. Toxic causes. 

5. Organic central lesions. 

6. Functional disturbances of the brain, such as epilepsy. 

Of all the manifold predisposing causes of convulsions in young chil- 
dren, the most important one is the natural instability of the nervous cen- 
ters, characteristic of early life, and associated with the non-development of 
voluntary centers of the cortex; hence it is that age is a most important 
factor in the etiology of convulsions; and under 2 years is recognized as 
by far the most susceptible period. Statistics show that over 60 per cent. 
of deaths from convulsions, up to 20 years, occur in infants under 1 year 
of age. Convulsions are not only more common in infancy, but much 
more fatal than later in life, and for reasons that are very apparent. It 
has been stated by some good observers that males seem to be more suscep- 
tible than females; statistics seem to justify this conclusion, but it has 
been suggested by others that inasmuch as more males than females are 
born each year, the larger number of deaths in males may thus be recon- 
ciled, for surely it would be contrary to reasonable expectation, as females 
are more delicately organized, while the exciting causes are probably about 
equal. 

The Peripheral Causes. — The peripheral causes are rachitis; gastric 
disturbances, such as acute catarrhal gastritis; intestinal worms; foreign 
bodies in the ear and nose, causing reflex convulsions; scalds and burns, 
and mental disturbances, such as fright, will induce convulsions. Lewis 
says: "Convulsions are in all probability due to an exaltation of the lower 
nerve-centers; or more frequently, to a suspension of the inhibitory power 
of the higher cerebral centers" — or both of these conditions may exist at 

(739) 



740 DISEASES OF THE NERVOUS SYSTEM, 

the same time — and further, "It remains to be said that we are still very 
much in the dark as to the immediate processes producing convulsions." 

"Infants have their nervous system in process of rapid development — 
only the component but undifferentiated parts of which are in great activity, 
ready to receive and re-energize limitless new impressions." At birth, the 
lower centers only are developed, and control is limited until the higher 
centers become competent to exert inhibition; hence in the earlier months of 
life convulsions are common, and less so after two years. 

Improper feeding may be looked upon as the most frequent cause of 
convulsions. A child that is improperly fed and suffers with a subacute or 
chronic form of dyspepsia, suffers with a deficient structure. Such struc- 
tural weakness resulting in rachitis, is a cause for that most common form 
of spasm known as laryngeal spasm and tetany. Toxemic conditions re- 
sulting from bacterial infection are a most frequent cause of convulsion. 

Pathology. — The development of the nervous system is not complete 
at birth. Very little light is shed upon convulsions by post-mortem findings. 
Usually after death from convulsions there is an effusion or haemorrhage 
found or there is a venous stasis in the brain. When death occurs from 
laryngospasm it results from suffocation. The condition of the brain in 
the beginning of an attack of convulsion is one of anaemia. This is shortly 
followed by a nervous hyperemia. The brain and meninges are usually 
found intensely congested and engorged. Sometimes punctate haemorrhages 
can be found. The lungs are also deeply congested and the right heart is 
generally distended with dark clots (Holt). 

Symptoms. — There is usually a loss of consciousness. The onset is 
sudden. A child may appear perfectly well up to the time of its convulsion 
and then suddenly the arms and legs become stiff, the eyes fixed and staring 
or rolled up under the lids. Eespiration is usually arrested, the head is 
retracted ; finally the whole body becomes rigid. 

The above named symptoms belong to the tonic stage. It is usually 
followed by clonic convulsions more or less severe and prolonged, affecting 
the upper and lower limbs, the face and eyes. 

Sometimes the tonic and clonic convulsions are few and the whole 
spasm may last less than a minute. Some children show no sign of illness 
after the attack is over, and appear perfectly normal. The attack may recur 
at short intervals. The child may then become comatose and die before 
proper treatment can be instituted. It is important to examine the urine. 
The possibility of a nephritis should not be overlooked. 

Diagnosis. — It is usually very simple to differentiate from epilepsy, 
which is most frequent after the third year. 

Convulsions usually are the first symptoms of the invasion of an acute 
disease. Scarlet fever, pneumonia, malaria, gastritis, and meningitis may 
be ushered in with convulsions. Measles is sometimes preceded by convul- 



CONVULSIONS. 741 

sions. Pertussis in which there is cerebral congestion may cause convul- 
sions. Bronchitis, membranous laryngitis, and laryngismus stridulus are 
sometimes preceded by convulsions. Do not suspect teething or worms as 
a cause of convulsions until all other causes have been eliminated. 

Treatment. — The treatment of convulsions consists of controlling the 
spasm. Inhalations of chloroform or sulphuric ether should be cautiously 
used, regardless of the age of the infant, until convulsions cease. 

Chloral hydrate and bromide of sodium, with some starch water, should 
be injected into the rectum; 5 grains each of chloral and bromide with a 
tablespoonful of starch water should be used and repeated every hour until 
the spasms are controlled. Leeching by the application of one or two 
leeches behind the ears is valuable to relieve cerebral congestion. We can 
also drain blood from the frontal sinus by the application of one or two 
leeches at the alse nasi. A mustard foot-bath should likewise be used until 
hyperemia of the skin is produced. While the feet are suspended in 
mustard water an ice-bag or a cold cloth should be applied to the head. 

A child, 4 years old, was suddenly seized with convulsions, clonic and tonic 
spasms involving the face, arms, and legs. From the history I learned that the 
child had overloaded its stomach, was very feverish, and thirsty. A mustard foot- 
bath was ordered and a rectal injection of: — 

R, Sodium bromide 10 grains 

Chloral hydrate 5 grains 

was injected into the rectum with two tablespoonfuls of thin starch water. 

One or two inhalations of chloroform were given to relieve the convulsions. 

The diagnosis of acute catarrhal gastritis was made and the convulsions 
attributed to a general toxsemia. When the convulsions ceased the stomach was 
washed with two quarts of warm water to which two tablespoonfuls of salt had been 
added. Food was discontinued and an interval dose of: — 

R. Sodium bromide 5 grains 

Chloral hydrate 2 grains 

was given every hour until the child was in a deep sleep. Twelve hours after the 
convulsions first began, thin soup and broth were ordered. The child was well in 
two days. 

To control convulsions: — 

R. Sodii bromidi 5 grains 

Chloral hydrate 5 grains 

Starch water . s 1 tablespoonful 

Mix thoroughly and inject, if possible, into the colon, through a small rubber 
catheter. Repeat every hour until convulsions cease. 

Lumbar 'puncture, the technique of which I describe elsewhere, is one 
of our most valuable therapeutic measures. By withdrawing 20 to 30 cubic 
centimeters of cerebrospinal fluid, I have seen marked benefit therefrom. 
The intracranial pressure which was relieved by this procedure, lessened the 



742 DISEASES OF THE NERVOUS SYSTEM. 

irritability of the child and promoted sleep. In a case of auto-intoxication 
due to gastric fever, with a temperature of 105° F. and over, in a child 
about eighteen months old suffering with continued convulsions, the follow- 
ing order of treatment was carried out: First, a colonic flushing to empty 
the bowel ; second, a tepid pack over the thorax ; third, a lumbar puncture, 
withdrawing about 25 cubic centimeters of colorless cerebrospinal fluid; 
fourth, a diet of whey, and plenty of water was followed by an amelioration 
of all the symptoms. 

Headaches. 

Various forms of headache are encountered in children. As a rule 
very little reliance can be placed on headaches complained of by young 
children. There are four kinds of headaches which are most frequently 
seen in older children : — 
• 1. Keflex headache. 

2. Headache due to general systemic cause. 

3. Headache of local origin. 

4. Headache due to brain lesions. 

Reflex Headache. — In chlorotic girls or in anaemic children headache 
is a common symptom. During menstrual disorders girls will usually com- 
plain of headaches. 

Hundreds of cases of headache due to eye strain have been seen by 
me in school children. These children complain of headache during and 
after school hours. The headache disappears during the night and the 
children never complain of headache in the morning. Most of these cases 
have been referred by me to an oculist, who as a rule finds astigmatism. 
The treatment consists in relieving the eye strain by wearing eyeglasss. 

Headache Due to General Systemic Causes. — Headache due to auto- 
intoxication resulting from impacted faeces is frequently encountered. 
Rheumatic children and children of gouty parents frequently complain of 
headaches. Such headaches are frequently found in lithaemia. The gen- 
eral constitutional treatment consists of a diet of vegetables, and fruit. 
No meat should be given. Five to 15 grains of citrate of potash will 
usually benefit this condition. A laxative should always be given if head- 
ache is due to constipation. Exercise and outdoor play will aid this 
condition. 

Headache Due to Local Origin. — Children frequently complain of 
headache which is due to intra-nasal neoplasms. At other times such local 
causes as supra-orbital neuralgia, due to neuralgia of the fifth cranial 
nerve, will cause an intense headache. In the latter instance gentle mas- 
sage or a mild current of faradic electricity will relieve. In severe cases the 
internal administration of 1 / 500 grain of Duquesnel's aconitia, three times 
a day, will relieve. In persistent headache it is advisable to have the ears 



SPASMUS NUTANS. 743 

carefully examined by a competent aurist. The frequency of middle-ear 
disease should be borne in mind. 

Headache Due to Brain Lesions. — In older children headache of a 
persistent character, associated with vomiting, should always be looked 
upon as suspicious of cerebral trouble. A case of this kind is reported by 
me in the chapter on "Cerebro-spinal Meningitis." In older children suf- 
fering with persistent headache it is advisable to examine the fundus of 
the eye to see if a choked disc is present. In one of my cases a tumor of 
the cerebellum was diagnosed in this manner. 

Migraine (Sick Headache: Hemicrania). 

This is a headache confined to one side of the head, associated with 
dizziness and generally vomiting. 

Causes. — Overworked school children of a nervous type usually have 
these attacks. Children suffering with dyspeptic attacks are more fre- 
quently the victims of migraine. An indoor life in a crowded apartment 
will cause this condition. Eye strain is frequently the cause. 

Treatment. — Have the eyes examined and correct any abnormality, if 
present. The diet should be regulated and a laxative dose 10 to 20 grains 
of phosphate of soda should be given. The value of bromide of soda in 
Seltzer water, with or without caffeine, should be remembered. 

Spasmus Nutans. 

This condition is frequently associated with rickets. It is characterized 
by an involuntary and uncontrollable head shake. 

Etiology. — It may be associated with or follow traumatism. Fright 
and other psychical disturbances may cause this condition. Heredity plays 
an important part in its development. It is usually found associated with 
rickets. In a case of mine presented to the Section on Pediatrics of the 
New York Academy of Medicine, 1 spasmus nutans was associated with 
sporadic cretinism. 

Symptoms. — In some cases we see a continuous nodding, in other cases 
the motion is Totary. In rare cases both motions, nodding and rotary, may 
co-exist. Nystagmus, which is a movement of the eyes, rhythmical and 
oscillatory, either vertical or horizontal, may also be present. 

Prognosis. — This depends on the cause of the same. As a rule the 
prognosis is good. 

Treatment. — If rickets is the cause give the child anti-rachitic treat- 
ment. If it is associated with cretinism, as in the case reported by me, 
then give thyroid treatment. A change of air and general restorative treat- 



See Proceedings of New York Academy of Medicine for 1904. 



744 DISEASES OF THE NERVOUS SYSTEM. 

ment are also beneficial in these cases. Electricity is not indicated and 
should not be used. Massage may be tried. 

Speech Defects. 

Stuttering. — This is a condition due to a series of contractions and 
spasms of the muscles concerned in speech. According to Scripture, the 
essential pathological fact is a special state of mind. 

Pseudo -stuttering. — This symptom is found in hysteria, cerebral spastic- 
ity, athetotic conditions, aphasia, and some forms' of amyotrophic lateral 
sclerosis. 

Lisping. — There are various types of lisping. Organic lisping is 
caused by a defect in the teeth, tongue, palate or ears. We may have 
negligent lisping due to a faulty perception and execution of sounds. This 
condition may be found in normal children as well as in those of deficient 
mentality. The necessity for proper medical supervision in the treatment 
of this class of cases is forcibly expressed by Scripture, 1 who maintains that 
the speech organs must be examined by a physician familiar with the anat- 
omy of the nose, throat, and larynx. In addition thereto, neurological 
training is necessary for a proper understanding of stuttering. Such cases 
should be sent to a proper clinic, where speech defectives can be classified 
according to their individual defects. 

Chorea (St. Vitus' Dance). 

This is a neurosis characterized by irregular, involuntary movements 
of the muscles. It usually affects the muscles of the extremities, face, and 
tongue. As a rule, these movements are not present when the child sleeps. 

Etiology. — As a rule, this disease is most prevalent between the ages 
of 7 and 14 j^ears. Chorea generally occurs in bright, precocious children. 
It is seen more than twice as frequent in girls as in boys, and the dispro- 
portion becomes even greater after puberty. It is extremely rare in dark- 
skinned races. Chorea rarely becomes chronic, although it recurs in about 
one-third of the cases. It is more likely to recur in girls. Fright and shock 
are frequently the causes of this disease. 

Steven Mackenzie 2 reports 439 cases. The largest number of attacks 
occurred in the thirteenth year. 

34 per cent, occurred between 5-10 years 

43 per cent, occurred between 10-15 years 

16 per cent, occurred between 15-20 years 



1 The Care of Speech Defectives, Medical Record, Feb. 22, 1913. 

2 British Medical Journal, February, 1S87. 



CHOREA. 745 

Sachs reported a case seen in a child under 1 year of age, and several 
cases seen in children between 2 and 3 years of age. The reported con- 
genital cases are usually mistaken instances of organic cerebral disease. 

Sinkler found that of 328 cases 232 were females and 96 males. 
Gowers studied the statistics of 1000 cases and found 365 in boys and 635 
in girls. 

Morris J. Lewis, of Philadelphia, studied 717 cases and found that 
the largest number occurred in March, the next largest number in May, 
and that the curve corresponds with the rheumatism curve. 

My own experience is that we have an equal number of cases occurring 
in the spring and fall, depending on the amount of study and the sedentary 
life induced by too much school. 

In a large children's service among the poor tenement population, out 
of 100 cases of chorea examined by me, 80 cases occurred in females; 20 
cases in males. 

All of my cases were school children who were apparently well when 
their chorea commenced. 

Overstudy in School. — Sturges, in London, has given considerable at- 
tention to the question of overstudy, and he believes that it is an impor- 
tant etiological factor in the causation of this condition. Overstudy (ap- 
parent) may mean only inability to study due to lack of mental concen- 
tration. 

Chorea frequently follows the infectious diseases. It is seen after 
scarlet and typhoid fever. I have seen chorea of a very severe type follow 
a fright and also after bad dreams, in school girls. Beflex causes, such as 
phimosis, pin worms, and delayed menstruation, are cited by some authors. 

Reflex Causes Due to the Eye. — I have usually sent children suffering 
with chorea to the eye specialist to see if improvement could not be ob- 
tained by using eye-glasses. I believe that headaches due to astigmatism 
can be relieved, so also can astigmatism be modified when suitable glasses 
are prescribed. I do not believe that the chorea per se was cured in a 
single case. I do not refer to those cases of habit spasm so frequently seen 
in nervous children, but I refer to distinct chorea. 

Vaginal discharges will frequently excoriate the vulva. This produces 
itching, and the scratching therefrom frequently induces masturbation. 
This is a frequent forerunner of chorea. 

Beflex conditions, such as adenoids and polypoids, have been reported 
from time to time. 

The reflex causes are overestimated. Adenoids are more likely to in- 
duce tics rather than chorea. 

Neurotic make-up plays a distinct predisposing role (neuroses or psy- 
choses in family). 



746 DISEASES OF THE NERVOUS SYSTEM. 

'Table No. 75. — The Association of Chorea with Rheumatism. 

Steiner reports 252 cases 4 suffered with rheumatism 

Sachs reports 70 cases 8 suffered with rheumatism 

Sinkler reports 279 cases 37 suffered with rheumatism 

Crandall and Holt report.. 146 cases 63 suffered with rheumatism 

Fischer reports 100 cases 25 suffered with rheumatism 

Twenty-five Per Cent, of my Gases had Undoubted Rheumatism. — 
By rheumatism I include cases that complained of pains in or around the 
joints. At times they were described as "growing pains" by the parent. 

Frequency of Endocarditis. — Valvular lesions have been seen by me 
in chorea without any antecedent joint lesions. The ease with which rheu- 
matism is overlooked in children makes the clinical history as given by 
parents doubtful. It is, therefore, possible that there are many more cases 
of rheumatism associated with chorea than are reported. 

Association with Tonsillitis. — Of the 100 cases of chorea previously 
reported by me, more than 80 cases had enlarged tonsils. It seems quite 
probable that the tonsil is the point of entrance of the pathogenic bacteria 
which cause chorea, and most probably rheumatism and endocarditis. 

Pathology. — There are no distinct pathological lesions which can be 
attributed to chorea. Sachs says that the pathology of chorea is still a 
great mystery. Not that autopsies are wanting, but there have been so many 
different post-mortem findings described that each writer may be said to 
have his own views concerning the pathology of chorea. 

Symptoms. — Chorea usually begins with prodromal symptoms. The 
children as a rule are very irritable, depressed, and cannot hold their arms 
or legs quiet. They complain of pain in various parts of the body. The 
main symptoms which attract the attention of parents or nurses are motor 
disturbances. These consist of involuntary twitchings affecting various 
muscles or groups of muscles. The muscles of the hands, the legs, the facial 
muscles, and the tongue show this choreic twitching. At times there is a 
decided interference with speech. A point worth noting is that the child 
cannot control these movements voluntarily. The greater the effort to con- 
trol these movements, the more the twitching will be noticed. Sachs em- 
phasized the fact that in doubtful cases choreic movements of the tongue 
will often prove the nature of the disease. This I have frequently been able 
to verify when it was a question of habit spasm or true chorea. There is a 
certain awkwardness which is typical in a choreic patient. This can be 
noticed when the child attempts to do anything. Choreic movements do 
not occur as a rule in the night when the child sleeps. The pupils are fre- 
quently dilated. Children are sometimes punished at school for restlessness 
which is the beginning of true chorea, and it is only later in the disease that 
the true character of the same is detected. In some cases but one-half of 
the body (hemi-chorea) is affected. In other cases choreic movements are 



CHOREA. 747 

stronger in the upper than in the lower extremities. Children seem to 
suffer muscular weakness and there is loss of muscular power. A peculiarity 
of chorea is that in spite of the constant muscular twitching there is little 
exhaustion. The reflexes show no abnormality. 

Condition of the Heart. — Very frequently a systolic murmur has been 
heard during the course of chorea. This systolic murmur persists for months 
after the last symptoms of chorea disappear. Pains in the large joints are 
frequently described. I have invariably noted a slight rise in the tem- 
perature (101° F.) when the joint pains or endocarditis existed. When 
chorea appeared without evidences of cardiac or arthritic complications the 
temperature invariably remains normal. 

Fannie S., 11 years old, was a very anaemic girl. She had been sick for two 
months with tonsillitis and influenza. She was compelled to stay away from school, 
and in order to catch up with her class, studied very hard, especially at night, until 
she passed her examinations. 

History Given by Mother. — The child complained of headache, her appetite was 
poor, the bowels constipated. She was restless by day and did not sleep well at 
night. She had nervous twitchings of the arms and legs. The fingers were never 
still. She did not appear contented at anything. Her eyes were examined by an ocu- 
list, who prescribed eyeglasses. He said the child had eye strain. The mother 
believed there was a slight benefit after wearing the glasses. 

When the child was brought to me, there were distinct evidences of chorea, with 
twitchings of the face, the tongue, the hands and the legs. Four drops of Fowler's 
solution was prescribed, three times a day, and gradually increased until 7 drops were 
given three times a day. All school and study was stopped. Cold sponging and a 
cold shower was ordered every morning and evening. Cereals, vegetables, milk, and 
fruit were given. All meat was stopped. An active outdoor life and all quiet games 
and sports were recommended. Under this treatment the symptoms gradually sub- 
sided and the child recovered. One year later the same symptoms returned, and it 
was found that the cause of the relapse was overstudy. I prescribed "remove the 
cause," namely, take the girl away from school. 

Course. — The usual course of this disease is from six to ten weeks, 
although it may extend to four months. I have seen cases in which there 
was a severe attack in the spring, which seemed to disappear entirely dur- 
ing the summer, and suddenly reappear with greater intensity in the fall. 

Prognosis. — The outcome of a case of chorea is usually good, especially 
so if we are dealing with intelligent mothers and nurses. The prognosis is 
bad if endocarditis or other organic lesions are associated. 

Treatment. — Rest Treatment. — It is useless to attempt to modify se- 
vere or mild chorea without enjoining absolute rest in bed. The eyes should 
be protected from a strong light, or the room should be darkened by drawing 
the shades. In some cases I have kept children in bed for one week before 
the twitchings ceased. In severer cases it may be necessary to keep a child 
in bed at least two or more weeks. The soothing influence of this absolute 
rest in bed will do more good than all the drugs combined. 



748 DISEASES OF THE NERVOUS SYSTEM. 

Hygienic Treatment. — A child should be removed from school and 
thus guarded against all psychical disturbances. Cold sponging of the en- 
tire body and cold spinal douches have been found very beneficial. 

The diet should be light and very nutritious. All cereals should be 
given (see diet list for a child from 3 to 10 years old, page 154). Meat 
should be avoided, although meat soups and white meat or chicken may be 
permitted. Later fresh air and quiet out-of-door exercise, games, and sports 
are necessary adjuncts in the treatment of this disease. 

Medicinal Treatment. — Iron and arsenic should always be remem- 
bered in the treatment of this disease. We can begin with 4 or 5 drops of 
Fowler's solution, three times a day, and watch the systemic effect, with 
gradually increasing doses until 10 drops, three times a day, are given. 
Great care should be used to avoid arsenical poisoning when large doses of 
Fowler's solution are given. In some children a peculiar idiosyncrasy 
exists which renders them liable to systemic poisoning. Semple has re- 
ported multiple neuritis following the' use of arsenic in the treatment of 
chorea. I have seen multiple neuritis in a rachitic child having chorea 
minor. The child received 4 drops of Fowler's solution for six weeks. 
When the arsenic was withdrawn, the neuritis subsided. Of the prepara- 
tions of iron. on the market, neoferrum in doses of 1 or 2 teaspoonfuls has 
served me very well. Another preparation which I have frequently used is 
the liquor f erri peptomangan (Gude) in doses of a teaspoonful, three times 
a day, after meals. Ferratin, 5 to 10-grain doses, three times a day, after 
meals, is also beneficial. Antipyrin and 'bromide of sodium may also be 
used in some cases. When chorea is associated with rheumatism, the salicy- 
late of soda in 3 to 5-grain doses, or salipyrin in the same quantity, may 
be given three or four times a day. Some authors advise against the use 
of chloral hydrate; my personal experience with 2-grain doses of chloral 
hydrate given morning and evening has been very good. If choreic twitch- 
ing does not improve after several weeks of persistent treatment, then a 
cold pack may be tried. A sheet wrung out in cold water at a temperature 
of 60° F. should be wrapped around the child for one hour every morning 
and evening. Not only have I seen a soothing effect on the nervous system 
from these packs, but they frequently promote sleep. That electricity is of 
value in this condition is doubted by many. I have seen one or two cases in 
which excellent results were obtained from the use of a weak galvanic cur- 
rent over the spinal nerves. On the other hand I have frequently seen no 
effect whatsoever from the treatment with mild or strong galvanic currents. 

Sachs recommends hyoscyamin in tablet form, 1 / 100 grain, when rest- 
lessness and insomnia exist. Hyoscyamin should only be administered in 
the afternoon and evening. Massage is sometimes of value in conjunction 
with electricity ; it has a soothing effect on the nervous system and stimu- 



HYSTERIA. 749 

lates nutrition. It is especially valuable at night and I have seen a pro- 
found sleep follow thorough massage of the body. 

Hysteria. 

It is an important matter to recognize this condition when met with 
in children. It is rarely seen in children under 7 years of age, although 
cases are on record of distinct hysteria having been met with in infancy. 
In my experience children rarely simulate disease. I have seen children 
imitate an invalid mother and complain of imaginary pains and aches at 
the same time and in the same portions of the body as the mother. Very 
neurotic children, susceptible children, and children having bad habits, such 
as masturbation, are more prone to develop hysteria. Charcot maintained 
that hysterical persons are hysterical because they are mentally degenerate. 

Pathology. — Hysteria is not a fatal disease, hence we have no specific 
pathological lesions. The theory concerning the mobility of the neuron, 
while very interesting and scientific, does not explain the hysterical par- 
oxysms. Hysteria is not a psychosis as is generally supposed. There are no 
known demonstrable lesions. While in some cases the whole brain seems 
disturbed and involved, in other cases but one-half of the brain is involved. 

Symptoms and Diagnosis. — Paralyses occur in hysteria which simulate 
those due to central nervous disease. As a rule, however, they disappear. 
The hysterical paroxysm usually follows close upon an aura. It sometimes 
comes on suddenly, although it may be preceded by a spell of laughing or 
crying. Children old enough to complain describe a "lump in the throat" 
similar to the "globus hystericus" which occurs in the adult. 

►Some symptoms closely resemble epilepsy. Headache is complained 
of at times. The screaming and shouting gradually cease as the attack 
subsides. The following description given by Taylor and Wells describes 
the attack so closely that I repeat it: "The patient sinks down or falls 
prone upon the back, with the limbs extended and rigid, but with the fingers 
and toes flexed; the eyes are usually rolled slowly from right to left, or 
crossed; the jaws are firmly closed; the breathing becomes slow and 
labored, and later hurried, the face flushed or bluish, the neck turgid; the 
cardiac action becomes more rapid and forcible, and consciousness is 
almost, but never entirely, lost. Sensation is much obtunded, and abolished 
in some portions of the body. Soon clonic movements succeed — a tremor 
affecting the muscles of the trunk, extremities, and face. This alternates 
with electric-like startings, during which the patient may fling himself 
furiously about, or actually out of bed. Presently this stage ends with 
sighs, and is followed by a short sleep." Some authors describe a series 
of dramatic movements. There may be opisthotonos. The child may have 
a bowing of the lumbar curve so that it rests upon its head and heels, 



750 DISEASES OF THE NERVOUS SYSTEM. 

There may be a series of attacks recurring so that as many as two hundred 
paroxysms have been recorded by Sachs. I have seen a severe form of 
hysteria with over ten paroxysms during one hour. Some tender areas 
frequently noted in children, over the ovaries and spine in girls, and the 
testicles of boys, are very sensitive. Some authors claim that pressure over 
these areas will sometimes invite an attack of hysteria; on the other hand 
pressure over these same sensitive areas will sometimes stop an attack. 

Vomiting when it does occur is a very serious symptom. We do not 
have the same forms of tremor as are seen in adults. 

Borborigmus (rumbling gas in the intestines) is occasionally heard in 
this condition. 

Epidemics of hysteria are frequently described. J. Madison Taylor 
describes one occurring in a church home at Philadelphia. I have fre- 
quently seen children in one locality suffer with various manifestations of 
hysteria, in which we could easily trace the origin to one particular child. 

Prognosis and Course. — The duration of the disease depends on the 
surroundings of the child. Mild hysteria will sometimes disappear after a 
change of scene and air of several weeks. In some instances a case may 
last years or through the child's whole life. -. 

It is always well to remember that hysteria is difficult to cure. If a 
child is sensitive and subjected to impressions from a neurotic family, then 
a cure will be. difficult. The outcome of any case of hysteria, depends on 
the character of the surroundings and on the mental influences with which 
the child is brought in contact, rather than on drug treatment. 

Case I. — A girl 9 years old was brought to me for the relief of headache. She 
complained of a continual headache night and day. The appetite was poor, the 
bowels moved sluggishly. She was restless during the day, and had insomnia at night. 
She complained of bad dreams. She looked haggard and worn, as though she 
were convalescing from some severe illness. She was anaemic and had cold extremi- 
ties. Heart, lungs, liver, and spleen were normal. She was a very restless child with 
marked hypersesthesia. The patellar reflexes were exaggerated. 

Subjective Symptoms. — The child complained of pain in every part of her body. 
On being asked, "Does your side hurt?" she answered, "Yes, my pains are in the side 
and in the back, just like my mother's." I referred the child to an oculist for an 
opinion as to the eyes, and his answer was: nothing abnormal, no astigmatism. The 
child cried on the slightest provocation, and was also almost convulsed with laughter 
for trivial matters. The diagnosis was hysteria. The child had a headache, or a 
backache, and always complained of some ache. It was quite evident that the child's 
hysteria was due to suggestion by the mother, who was an invalid. 

The treatment consisted in removing the child to an aunt in a neighboring city, 
ami4 healthy surroundings. Iron was ordered to build up the system,. and bromide 
of soda in 10-grain doses was given every night for one week, later every other night. 
Electricity, the baths, and massage were used with great success. In three months 
the child had rosy cheeks, slept well, was cheerful, and did not complain of any pain. 
It was strange, however, that when taken back to her mother, she immediately re- 



MULTIPLE NEUKLTIS. 751 

lapsed into her former habit of complaining. We determined to remove her per- 
manently, and she remained well for over a year when I last heard of her. 

Case II. 1 — General Hysteria and Nervous Vomiting. — A girl 12 years old was 
brought to my children's clinic for the relief of vomiting. She was very nervous 
and complained of pains all over her body. She complained also of pains in her 
stomach before and after eating. Her mental condition was poor, the hands and 
feet were cold. She complained of epigastric pains for the last six years. From 
the mother I learned that the child was frightened by a dog and since that time she 
has been very sensitive to the slightest impression. The gastric contents were 
syphoned off after a test meal and a hyperchlorhydria was found. The urine con- 
tained acetone. 

The treatment of this case was most successful when large doses of bromides 
were given. 

Treatment. — Study the cause or causes, and remove them if possible. 
Change the surroundings of the child by removing to a cheerful but quiet 
home. If the case occurs in the country, bring the child to the city. In 
any event the main point should be to change the entire scene and sur- 
roundings. If a child is in an institution, remove it from the same if it 
is at all possible. The person in charge of the child should be either a 
very intelligent mother having a positive influence over the child, or a 
mild-mannered trained nurse. All orders of the physician should be 
strictly obeyed without having the child feel that vigorous treatment is 
being used. This psychosis requires educational treatment as has just been 
described. 

Hygienic Treatment. — If the child is old enough, a walk should be 
ordered several times a day. The bicycle and horseback are valuable ad- 
juncts. The sponge bath or the tub-bath aided by a cold shower or spray 
chiefly over the spine, head, and neck, have very tonic properties. 

Hydrotherapy properly used is one of the most valuable aids in pro- 
moting a cure. 

Nothwithstancling the shock of a cold spray, the same should be ordered 
winter or summer. 

After the bath the body should be rubbed vigorously, or better yet, 
massage should be given. I have always found a very soothing effect on 
the nervous system by giving gentle but thorough massage. Another reme- 
dial agent which must be used regularly is electricity. This should be used 
daily by means of a mild f aradic current, one electrode to be applied over 
the spine, the other over the phrenic nerve. If no benefit is noticed after 
this treatment is tried, then static electricity can be used. 

Multiple Neuritis (Polyneuritis). 
This is frequently termed a peripheral neuritis, as it is an affection 
of the terminal branches of the nerves. It usually affects all the nerves 



1 This case was presented by me to the Section on Pediatrics, Academy of 
Medicine, February 14, 1901. 



752 DISEASES OF THE NERVOUS SYSTEM. 

of the limbs on both sides of the body. Starr gives the following classifica- 
tion : — 

"1. Toxic cases due to the action of a poison derived from without 
the body. These poisons are alcohol, carbonic oxide gas, bisulphide of car- 
bon, the coal-tar products, especially sulphonal and trional; and nitro- 
benzol; also, arsenic, lead, mercury, copper, phosphorus, and silver. . 

"2. Infectious cases due to some agent acquired or developed within 
the body, as an accompaniment or sequel of diphtheria, grippe, typhoid, 
typhus, malaria, scarlet fever, measles, whooping-cough, smallpox, erysipe- 
las, and septicemic conditions, including gonorrhoea and puerperal fever, 
epidemic forms of beriberi or kakke, and leprous neuritis. 

"3. Cases due to general diseased states of the body whose origin is 
undetermined, such as rheumatism, gout, diabetes, anaemia, marasmus, gen- 
eral malnutrition consequent upon tuberculosis, syphilis and senility, car- 
cinoma, and local malnutrition produced by arterial sclerosis. 

"4. Cases due to exposure to cold and developing spontaneously with- 
out known cause." 

The most common type of multiple neuritis met with in children is 
either the diphtheritic type or that resulting from poisons in the blood, 
such as the prolonged administration of Fowler's solution (arsenical poi- 
soning). 

Symptoms and Diagnosis. — Multiple neuritis may come on suddenly 
or the onset may be gradual. The- special senses are rarely involved in 
this condition. The motor symptoms are as marked as the sensory. Paral- 
ysis comes- on first as a muscle weakness, and gradually increases until dis- 
tinct paralysis is present. The extensor muscles of the wrist, hands, and 
feet give the wrist-drop and the foot-drop. Very rarely the muscles of all 
four extremities in addition to the muscles of the trunk and neck are in- 
volved. The knee-jerk usually disappears early when neuritis follows diph- 
theria. The paralyzed muscles are relaxed, flabby, and atrophied. An 
important symptom is that faradic excitability is absent and that the mus- 
cles respond to a galvanic current only. This symptom is identical with 
that found in acute anterior poliomyelitis. The reaction of degeneration is 
present. 

There is usually no incontinence of bladder and bowel. Atrophy is 
another prominent symptom. The condition is similar to that seen in 
poliomyelitis. There may be other vasomotor disturbances such as uni- 
lateral flushing of the skin, or small areas may show a high glossy flush. 
This last symptom was very prominent in one of my cases. An oedema 
of the affected parts is described by some authors. As a rule the areas 
affected are very sensitive, so that we have distinct hyperesthesia. In other 
cases the opposite condition prevails and there are areas of local anesthe- 
sia. The disease may be ushered in by a fever. The temperature may rise 



PAYOR JS'OCTURNUS. 753 

to 103° or 10-4° F., and remain several days. The pulse-rate is correspond- 
ingly increased and may reach 140 or 160. 

Gastric disturbances associated with diarrhoea may be present. The 
spleen is frequently enlarged, and an examination of the blood will show 
a distinct leukocytosis, the latter condition when neuritis is a sequela to 
an infectious disease. 

Course and Prognosis. — As a rule, multiple neuritis lasts from several 
weeks to several months, and then ends in recovery. The cases seen by me 
associated with chorea in which arsenical poisoning took place, invariably 
improved when the drug was withheld for a short time. Barely does the 
paralysis remain permanent. The prognosis can best be gauged by noting 
the electrical reactions. If the reaction of degeneration is present after 
the disease has lasted several months, then a permanent lesion must be 
suspected. If, on the other hand, there is only a slight difference in the 
reaction following the use of the faradic current, then a complete recovery 
may be expected. Some cases, although severely atrophied, will ultimately 
recover. If myelitis complicates this condition, the prognosis is serious. 

Treatment. — The system should be strengthened with proper nutrition. 
The patient should be made as comfortable as possible. If severe pains 
exist, then large doses of bromide should be given, with or without codeine, 
until all pain is relieved. In some cases the local application of warmth 
over the affected limb is very soothing. I frequently use a warm bath at 
night, which is very soothing and promotes sleep. 

Gentle friction and massage are beneficial. Bestoratives, such as cod- 
liver-oil, maltine with hypophosphites, and iron should be used. The 
syrup of the iodide of iron is a good restorative. Butter, cream, and 
cereals are excellent tonics. Strychnine and mix vomica are valuable if 
the appetite is poor; otherwise they have no specific value. 



Payor Nocturnes (Night Terrors). 

Children apparently healthy will sometimes awaken from a sound 
sleep and shriek or scream. 

Etiology. — In this condition children usually show some disturbance 
of the stomach or bowels which may have been the exciting cause of the 
night terror. Beflex irritability is frequently caused by intestinal worms, 
by adenoid vegetation, or in the male child by an elongated prepuce, or 
by phimosis. Such children usually possess a neuropathic constitution by 
inheritance. Henoch states that some children may have hallucinations 
during the day. These attacks occur but once during the night, and after 
reassuring the child that there is no danger, it will again fall asleep. 

Symptoms. — Some children awaken frightened and screaming, while 
others will grasp anything within reach in a bewildered manner. They 

48 



754 DISEASES OF THE NERVOUS SYSTEM. 

frequently imagine that animals are in the room. The effect of too rigid 
discipline will sometimes show itself by bad dreams at night, and in a 
distinct hysterical symptom, such as fright and terror. 

Course and Prognosis. — If these night terrors are associated with mild 
nervous attacks during the day, or if they partake of the nature of epileptic 
attacks, then a cautious prognosis should be given. The inclination to 
serious brain or nervous trouble must always be remembered; therefore, 
no opinion should be ventured until a case has been properly observed. 

Treatment. — Children having night terrors should be removed from 
school to insure perfect tranquillity. There should be a distinct change of 
scene, a change from the city to the country, or vice versa, will be bene- 
ficial. Any reflex cause, if present, should be attended to, and, if possible, 
removed. Fresh air, out-of-door life, and restoratives are indicated. Such 
children appear less frightened if they sleep in the room with an adult, 
and are thus reassured that there is no danger present. 

Cold or gradually cooled bathing or a spray over the spine will tone 
the nervous system. It should be used in a warm room daily. Five grains 
of sodium bromide may be given before retiring. 

Masturbation ( nanism ) . 

This habit is very frequently seen in children. I have seen it in girls 
as well as in boys. 

Causes. — Any irritation of the genital tract that will cause itching 
may be the origin of masturbation. In boys an elongated prepuce, or 
friction from phimosis, may giye rise to this condition. Very acid urine 
may cause excoriation and thus invite this bad habit. Excoriations at or 
near the external meatus may be the starting point. We see this condition 
quite frequently in girls when preputial adhesions due to smegma or dirt 
cause an irritation of the clitoris or when pin worms wander from the anus 
to the vagina ; thus worms frequently set up an irritation resulting in mas- 
turbation. A diaper if too tightly pinned can set up an irritation, especially 
in female children. 

Symptoms. — Children usually place their hands on the genitals and 
masturbate. They sometimes rub their thighs together until exhausted. 
During this friction their face will be flushed and they appear irritable. 

Such children suffer with profound anaemia as the result of this habit; 
and from loss of sleep. Older children, especially boys, will masturbate 
chiefly at bedtime. They are peevish, irritable, and very sensitive. 

An infant about nine months old was seen by me in consultation with Dr. L. 
F. Harris, of New York City. The mother complained that the child continually 
rubbed its thighs. The face was flushed during the rubbing; later the child would 
fall asleep as though from exhaustion. This condition seemed to occur chiefly when 



MASTURBATION. 755 

the child was placed on the bed or held on the lap. An examination of the genitals 
showed that they were very red and excoriated from the constant irritation. 

The prognosis is usually good if the habit is detected early and the 
cause removed if one exists. On the other hand, some cases will persist 
in spite of careful treatment, and nothing but heroic measures will effect 
a cure, as the following case will illustrate : — 

An infant, female, was brought to me for the relief of this condition. The 
child had masturbated continually for several months and was so emaciated that 
the parents were alarmed. The condition was so bad that the child masturbated 
whenever the thighs were put together. A pad was improvised to separate the thighs 
and local applications of lead water on cotton were placed over the genitals to reduce 
the irritation. Large doses of bromides were administered to control irritability in 
the nervous system. The child was kept in a stupor for several days without having 
the condition relieved. The symptoms persisted and we finally were compelled to 
remove the child to the St. Marks Hospital where Dr. H. J. Garrigues suggested per- 
forming a clitoridectomy. This case was published in extenso in Archives of 
Pediatrics, May, 1899. The child made a perfect recovery. The habit did not 
reappear. 

Treatment. — Eemove the cause if any exists. All irritants, such as 
worms or eczema, should be treated. If an enlarged prepuce causes this 
condition, remove it. If a vaginal discharge exists, treat it with astrin- 
gents, and thus avoid irritation. If worms are present, injections of quassia 
will dislodge them (see chapter on "Worms"). In older children we must 
remove the child from bad company, and sometimes it will be necessary to 
change the entire surroundings of a sensitive but well-meaning child. An 
ocean voyage is beneficial. The system should be strengthened by giving 
iron and strychnine. Clean habits, a rigid hygiene, and a daily bath are 
necessary. Strict supervision by night as well as by clay with the aid of 
a trained nurse will do more good than medicine. Children once detected 
with this bad habit must never be permitted to sleep with their hands under 
the bedclothes. 

Circumcision is one of the most valuable means of curing this habit. 
In females, especially in little girls, stripping the clitoris and cleansing the 
smegma, if present, will frequently modify this habit. If the habit persists 
in spite of this treatment, then a radical operation — clitoridectomy. (see 
clinical case given) — may be required. 



CHAPTER III. 
SPASMOPHILIA. 

The modern conception of tetany, true laryngeal spasm, spastic apncea 
and convulsions is that they are one and all part of the clinical picture 
known as spasmophilia. The condition is characterized by an irritability 
of the nervous system. 1 

It is most commonly met with in early childhood, and distinguished 
by galvanic and mechanical hyperexcitability of the peripheral nerves ; both 
tonic and clonic convulsions are frequently associated. 

Etiology. — There is a diminution in the quantity of calcium salts in 
the brain, and a corresponding increase in calcium phosphates in the urine. 




Fig. 250. — Tetany. Characteristic attitude of the hands resembling a 
rider reining in his horse. Note attitude of the toes. The wrists are 
rigid and flexed. The elbows are free. The fingers are flexed at the meta- 
carpophalangeal joints. In this case facial irritability was best seen by 
constant spasm in the orbicularis palpebrarum. (Original.) 

Musser and Goodman found a high percentage of ammonia in the urine, 
rarely below 5 per cent. This output of ammonia bears a distinct relation 
to tetany. Berkley and Beebe believe that the parathyroids are concerned 
in furnishing enzymes which are of importance in the intermediary metab- 
olism of nitrogen. Jacobson found an increase of ammonia in the blood 
and believes that such ammonia is sufficient to cause tetany and tremors. 
The removal of the parathyroids alone causes tetany. For this reason the 
extract of the thyroid gland has been advocated for the relief of this 
condition. 

Von Pirquet 2 has noted specific conditions: that in the normal in- 
fant the anodal opening contraction does not occur with less than 5 



1 Sedgwick, J. P.: St. Paul Medical Journal, Oct., 1912. 

3 Von Pirquet: "Galvanische Untersuchungen an Sauglingen," Verhandl. d. 
Gesellsch. f. Kinderh., Stuttgart, 1906. Bergmann, Wiesbaden, 1907. 

(756) 



SPASMOPHILIA. 757 

milliamperes. In spasmophilia the contraction by application of the Stinzing 
normal electrode applied over the median or peroneal nerves can be pro- 
duced with less than 5 milliamperes upon the anodal opening. The reactions 
upon anodal closing and cathodal closing and opening are also frequently 
obtained with less current than in the normal child ; that is, with less than 
two for cathodal closing, three for anodal closing, and five for cathodal 
opening. 

By studying these reactions we have been able to learn that the under- 
lying condition — namely, spasmophilia — is responsible for most of the con- 
vulsions in children, true laryngeal spasm, tetany, and spastic apncea. 
Thus, we may state that if an anodal or cathodal opening contraction with 
a current less than 5 milliamperes is present, it shoivs that spasmophilia, 
latent or active, is present. This condition is most common after the fourth 
month and is rarely found after the second year. 

Symptoms and Diagnosis. — Gastro-intestinal derangements in the artifi- 
cially fed infant are responsible for most, if not all, forms of spasmophilia. 
Active symptoms of spasmophilia frequently disappear when an improperly 
artificially fed infant is put to the human breast. 

If we tap the muscles of the jaw, a slight contraction of the face 
ensues. This is known as the facial phenomenon, and was first described 
by Chvostek. The contractions are first seen in the orbicularis palpebrarum. 

The contraction resembles that caused by the sudden passage of a 
galvanic current. It is sometimes more marked on one side of the face 
than the other, and in some cases it is more noticeable in the upper — in 
others in the lower — half of the face. A similar contraction of the inner 
end of the eyebrow may often be caused by tapping on the temple. The 
wrists are rigid and flexed. The elbows are free. The fingers are flexed 
at their metacarpophalangeal joints. There may be a constant spasm, 
jerking in character, continually present. 

A similar phenomenon is known as Trosseaus sign; if the arm is com- 
pressed by an elastic band the muscles of the fingers and sometimes of the 
forearm pass into the tetanic condition. 

Course. — The course of this disease is given by some authors as from 
a few days to several weeks. In one case observed by me at the Willard 
Parker Hospital (see Fig. 250), the tetanic spasms lasted for more than two 
months. Other cases seen by me lasted but a few days or -weeks at the 
longest. 

Prognosis. — The prognosis is excellent if the cause of the tetany is a 
gastro-intestinal disorder. 

There are instances in which death has ensued from laryngeal spasm 
or from general convulsions. When a very frail infant has severe tetany 
.of the upper and lower extremities with retraction of the head, then the 
prognosis is bad. 



758 DISEASES OF THE NERVOUS SYSTEM. 

Treatment. — The deficiency of calcium salts has given us a clue to 
therapeutics, showing that probable imperfect metabolism of certain mineral 
salts is responsible for this condition. 

The thyroid gland has been successfully employed in the treatment 
of tetany. It may be administered raw or in the form of a dried gland in 
doses of 1 to 5 grains per day. 

Thorough cleansing of the gastro-intestinal tract is demanded. For a 
child 1 year old, a 3-grain compound jalap powder, combined with y± grain 
calomel, may be given on awakening, and repeated if necessary the following 
morning; 1 / 250 grain phosphorus dissolved in one-half teaspoonful of cod- 
liver oil may be given three times a day after meals. 

The diet should consist of skimmed milk, expressed beef juice, chicken, 
or lamb broth thickened with barley or farina, steamed rice or farina, 
arrowroot boiled in milk, puree of peas, stewed fruit, bread, crackers and 
butter. Meat and eggs should be eliminated from the diet. Water may 
be given liberally. 

Tetanus (Lock Jaw). 

This acute infectious disease is caused by the invasion of a specific 
micro-organism. 

Etiology. — <Any open wound on the surface of the body can be the 
point of entrance for these pathogenic bacteria. 

There are some parts of our country in which the disease exists all 
the year round, provided the factors which cause the same, filth and dirt, 
are brought into play. A' child infected with tetanus can transmit the 
disease ; hence this should be borne in mind while a case is under treatment. 

Bacteriology. — Nicolaier in 1884 found a specific micro-organism in 
the soil from which he infected animals and produced tetanus. He also 
found this germ present in patients affected with tetanus. 

In 1898 Kitasato demonstrated this bacillus in pure culture. It was 
also found in infants suffering with tetanus. From the pure culture 
Kitasato and Behring produced an antitoxin. 

The toxin generated by tetanus is a deadly poison. Kitasato found 
that an animal which was infected and left alone died in one hour. 

Pathology. — Distinct lesions of tetanus cannot be demonstrated patho- 
logically. An open wound and evidences of a general septic infection can 
usually be found. Haemorrhages of the brain or smaller haemorrhages in 
various parts of the body may exist. If the umbilicus has been the point 
of entrance, the wound will not heal. 

Symptoms. — In the new-born the first symptom noticed is the refusal 
to take the breast. Owing to the rigidity of the muscles, the jaws will be 
found stiffened and feel hard to the touch. The same spasmodic stiffening 
will be made out in the other parts of the body. After a sudden stiffening 



TETANUS. 759 

the muscles usually relax. Muscular rigidity appears in paroxysms and 
may come on every few minutes. 

The temperature varies between 101° and 104° F. or there may be 
hyperpyrexia reaching 107° F. The pulse is small, feeble, compressible, and 
very rapid. Symptoms of malnutrition, such as emaciation, are very evi- 
dent. Stadtfeldt reports 88 fatal cases; 83 of these died between the ages 
of six and ten days. 

The following case illlustrates tetanus seen in private practice : — 

A female infant fifteen days old was seen by me suffering with fever. The 
nurse said that she refused the breast. The infant was in good health apparently up 
to this time. The appetite was good, the bowels regular, no gastric disturbances 
existed. On examination the umbilicus was found inflamed and suppurating. The 
temperature was 102° F.; the pulse 160. The jaws were fixed. The infant had 
spasms, which grew more severe when she was handled. The body relaxed for a 
few minutes at a time. 

The treatment consisted in cleansing the wound with strict asepsis, dusting 
europhen powder on the umbilicus, and protecting the same with a sterile bandage. 
The rectum and colon were flushed with warm saline solution. An injection of 5 
cubic centimeters of antitetanus serum was given with the usual antitoxin syringe. 
As no effect was evident from the injection, a second injection of 5 cubic centimeters 
was administered twelve hours later. Symptoms of improvement followed and the 
child recovered. 

A second case of tetanus was one caused by scratching an open wound situated 
near the nose, while playing with a canary bird. Symptoms of tetanus appeared 
two days after infection. This case was also seen in consultation by Dr. George F. 
Shrady. Large quantities of tetanus antitoxin were injected with no beneficial 
result. The case ended fatally. In this case the infection was traced to some 
canary birds which were in the same room as that, occupied by the family. 

Prognosis and Course. — The duration of fatal cases is seldom more 
than one or two days. Those tending to recovery usually extend from one 
to three weeks. 

While occasionally cures are reported, five out of ten seen by me have 
ended fatally. I have seen cases, both in this country and abroad, injected 
with, sufficient antitoxin, end in recovery. 

Treatment. — An injection of 30 cubic centimeters tetanus serum should 
be given, and repeated every twelve hours until the toxic symptoms improve. 
In addition thereto, the bromides of potassium and sodium, chloral hydrate, 
belladonna, and opium are among the anti-spasmodics used. It is essen- 
tial to give large doses or no effect will be produced. Calabar bean has been 
lauded by some authors and can be given hypodermically. 

The literature records a great many cases where the antitoxin was in- 
jected directly into the brain. In the new-born baby this method should be 
used, as there is no obstacle to the introduction of the needle through the 
open fontanel. 

In one case treated by me the antitoxin was injected through the ante- 
rior fontanel. 



700 DISEASES OF THE NERVOUS SYSTEM. 

Epilepsy. 

Epilepsy is frequently seen in very young children. Some writers state 
that it develops in children approaching puberty. I have seen epileptic 
spasms in children under 1 year of age. 

Etiology. — Children whose parents are drunkards, or where nervous 
diseases exist, are predisposed to this condition. According to Berkley, 33 
per cent, of these cases give a history of alcoholism in one parent. Eachitic 
infants are frequently seen with epileptic seizures, so that it is quite pos- 
sible that they are predisposed. Children who have suffered with convul- 
sions in early life frequently have epilepsy later in life. This has led some 
authors to believe that convulsions and epilepsy are as cause and effect. 

Undoubtedly many cases of this kind exist. Statistics prove, how- 
ever, that one-half of all eclamptic children have no further nervous dis- 
eases in later life. Hence, we must not claim that if an infant suffers with 
eclampsia it must necessarily become an epileptic. 

An injury to the head, fright, or sunstroke may possibly cause this dis- 
ease. Some authors state that epileptic convulsions are intimately asso- 
ciated with adenoid vegetations, phimosis, and masturbation. Foreign 
bodies in the nose, throat, and ear may occasionally be predisposing factors. 
Other writers believe that menstrual disorders will provoke epilepsy. 

"The etiology of idiopathic epilepsy is mainly to be sought in alco- 
holism in the parents, which induces a defective organization of the brain 
structures in the descendants. Inherited syphilis is a less frequent factor. 
The signs of inheritance are chiefly seen in the departure from the normal 
in the skull formation, microcephalus, macrocephalus, as well as asym- 
metries of the skull and facial bones. Flatness of the cranial arch is found 
in a considerable proportion of epileptics, particularly among the males. 
Signs of rickets are especially frequent in epileptic children. Aronsohn, 
in a study of heredity among 508 epileptics, found a history of neuro- 
pathic disease in the parents in 32 per cent. Females showed a stronger 
tendency to inherit the disease than males, 33 per cent, against 30 per cent. 
The disposition on the part of the mother to transmit epilepsy is greater 
than that of the father (39 1 /2 against 29 per cent, of inherited cases). 
Where both parents were hereditarily burdened, 63 per cent, of the children 
inherited the disease. In 82 per cent, of the inherited cases, the disease 
began before the twentieth year of life. Wildermuth, in 145 cases of early 
epilepsy, found inherited tendencies in 49 per cent., drunkenness on the 
part of the parents contributing nearly one-half (21 per cent.) of the 
examples. Traumatism in early life furnishes a small number of cases 
of epilepsy. Among 210 patients assembled by Wildermuth antecedent 
injury to the head had occurred eight times. In the majority of the trau- 
matic cases, the seizures followed the injury within a few days or weeks, 



EPILEPSY. 761 

seldom after months. Epileptiform seizures and their sequelae are some- 
times found where there has been antecedent meningitis, porencephalia, or 
cerebral haemorrhage in infancy; they may also result from acute infec- 
tious processes, but in these instances they are to be regarded not as be- 
longing to true epilepsy, but as the symptomatic expression of a coarse, 
irritative cerebral lesion" (Berkley). 

Pathology. — Gowers states that the disease is probably located in the 
gray matter of the cortex. It should be regarded as a muscular- spasm, the 
result of the sudden overaction or discharge of the nerve cells. 1 

Of 1450 cases of epilepsy studied by this same writer, 12 per cent, 
began during the first three years of life, and 46 per cent, between the 
tenth and twentieth years. 

An interesting point was brought out by Herter and Smith, 2 who 
studied 238 specimens of urine taken from 31 epileptics. 

They noticed that in 72 of these observations there was excessive in- 
testinal putrefaction, as shown by the presence of ethereal sulphates in the 
urine just before the occurrence of the spasm. These authors were war- 
ranted, therefore, in their conclusion, that there is a distinct association 
between the intestinal poisoning and the epileptic seizures. We can readily 
see that the treatment of any case of epilepsy must be followed along the 
lines just described. 

Symptoms. — There are two kinds of attacks usually met with : first, 
the grand mal; second, the petit mal. 

Grand Mal Form. — The attack may come on gradually or it may be 
sudden. Children old enough to complain frequently have a warning of 
the attack known as the aura. This aura consists in a series of symptoms, 
such as a twitch in the leg or the face, constituting a local spasm described 
by some authors as a "motor aura." Then again. there may be abnormal 
sensations, such as a tingling or numbness in any part of the body, until 
the patient suddenly falls with the spasm. There may be an unusual 
tremor or a shivering sensation, and the patient may fall to the floor with 
a sharp cry, having the jaw set and all the muscles of the body in tonic 
spasm. The eyeballs are usually rolled upward. After a few seconds, dur- 
ing which the skin is cyanotic, a second stage follows, in which there are 
clonic spasms. There may be involuntary spasms of the bladder and bowel. 
In the clonic stage the muscles frequently contract and relax violently. 
Not infrequently the tongue is apt to be caught between the teeth and is 
bitten. There may be frothing at the mouth. Very marked rigidity of 
the sterno-cleido-mastoid. The head may be thrown backward or it may 
be twisted to one side. The extremities may relax and then become rigid 
again, and the cyanosis gradually disappears. Children usually fall into 



1 Gowers: Diseases of the Nervous System, Amer. Ed., 188! 

2 New York Medical Journal, August and September, 1892. 



762 DISEASES OF THE NERVOUS SYSTEM. 

a deep sleep as though exhausted after the end of the clonic stage. This 
sleep lasts hours at times. Children old enough to describe symptoms will 
state that they have no knowledge of what has happened. They awake just 
as children do after a deep chloroform narcosis. 

Petit Mai Form. — This is a milder type of the condition above de- 
scribed. The attacks, instead of lasting minutes and hours, usually last 
but a few seconds. The child does not fall, but may sit quietly during the 
seizure until it passes off. 

An aura is absent in this condition. The attacks not infrequently 
happen several times a day. They may also occur at night. In some 
children we have both varieties. 

Differential Diagnosis. — Epilepsy is frequently confounded with hys- 
teria. In hysteria there is partial consciousness. In epilepsy there is a 
loss of consciousness. The biting of the tongue and symptoms, such as the 
nocturnal appearance of the attacks, will aid in establishing the diagnosis. 
There is usually a dilatation of the pupils. 

An epileptic may have an attack in inopportune places, such as the 
street or on a hot stove, whereas a case of hysteria usually selects a place 
indoors, entirely out of danger. 

Prognosis and Course. — This disease does not follow a regular course. 
The usual interval between seizures in the very beginning may be months. 
Eegular intervals of epileptic attacks may be every two or four weeks. In 
some severe cases seen by me the attacks came on every day. It is not 
unusual for epileptic seizures to come at night only. When such is the 
case, the diagnosis is very difficult. 

The outcome depends on the condition of the patient. A child may be 
seized with an attack while on the street and be killed by an accident. In- 
stances are on record where epileptics have fallen into the water and were 
asphyxiated during the spasm. Traumatic epilepsy will occasionally be 
cured by surgery. Generally speaking, the cases of epilepsy seen by me did 
not do well with surgical treatment. 

Treatment. — A case of this kind should never be left alone, owing to 
the danger of accident during the epileptic seizure. If a cause exists, such 
as adenoid vegetations or phimosis, the same should be radically treated. I 
have previously mentioned the results of Herter's examinations of the urine ; 
thus, we find that the products of indigestion are usually found in epilepsy. 

Dietetic Treatment. — Arguing from this point of view, the stomach 
and bowels must not only be constantly supervised, but the lightest kind of 
nutrition that will yield strength should be ordered. The action of the 
bowels must be frequent. The slightest constipation should not be per- 
mitted. 

Cereals, vegetables, and fruits, in fact, the lightest kind of dairy 
products, should be ordered. Meat and similar stimulating nutrition should 



EPILEPSY. 763 

be enjoined. Water and liquids should be freely given. Neither alcohol, 
tea, nor coffee should be allowed. 

Hygienic Treatment. — Children so afflicted should be kept out of doors 
as much as possible. They should not attend school. They should have 
Cheerful surroundings and avoid all useless excitement. They should be 
given a bath daily and a proper amount of sleep. 

Drug Treatment. — Sodium bromide seems to be the drug par excel- 
lence in the treatment of this disease. Children can take as large if not 
larger doses of bromide than adults. I have frequently given 1Q grains of 
bromide of soda to a child 1 year old, and repeated the same several times 
a day. 

We must study the tolerance of every child by carefully increasing 
the dose until the physiological effect of the same is produced. Seguin 
advises giving large doses early in the morning, small doses during the day, 
and large doses at night. The reason for the large dose at night is the fre- 
quency with which the attacks appear in the night. Belladonna is advised 
by some authors. Chloral hydrate is frequently useful when combined 
with the bromides. I sometimes use arsenic alone when the bromides cause 
acne. 

Crotalin is the dried venom taken from the fangs of the American 
rattlesnake. ' It is well spoken of by some writers in the treatment of this 
disease. It is injected into the back of the forearm in V 200 -grain doses. 

Restorative treatment should be combined with this anti-spasmodic 
treatment. The system should be strengthened by giving iron and strych- 
nine. The use of malt extracts and codliver-oil will be found beneficial. 
Regarding the surgical treatment of epilepsy, Sachs says : — 

"In a case due to a traumatic or organic lesion an early operation may 
prevent the development of cerebral sclerosis. If an early operation is not 
done, the occurrence of epilepsy is a warning that secondary sclerosis has 
been established and an operation may prevent it from increasing. Opera- 
tion must include the removal, of the diseased area; here, if all other parts 
are normal, a cure may result. Under favorable conditions a few cases of 
epilepsy may be cured by surgery and many more improved." 

Surgical Treatment. — Geo. W. Jacoby advises as a prophylactic meas- 
ure to operate early, that every head injury or suspected fracture should be 
trephined. Thus, an operation is indicated in suspected organic focal dis- 
ease of the brain. If meningeal haemorrhage due to traumatism is sus- 
pected, an operation will do good if performed early. Concerning the ex- 
cision of a piece of the cortex to remove a scar, he does not believe any 
permanent benefit is derived therefrom, because a larger scar results. 

B. Sachs and A. Gerster 1 give the following summary: An opera- 
tion is permissible in traumatic epilepsy when the case is not over 1 or 



American Journal Medical Science, October, 1896. 



7G4 DISEASES OF THE NERVOUS SYSTEM. 

2 years old. When there is a depression of bone, the operation is indi- 
cated at a later period, but should not be delayed. Trephining alone is 
sometimes sufficient. If the disease is of short duration, a part of the 
cortex may be incised. The complication of infantile cerebral paralysis, if 
the case be recent, is no contraindication to the operation. It must not be 
performed in epilepsy of long duration. 

Acute Myelitis. 

This condition consists in a diffuse inflammation resulting in destruc- 
tion of spinal elements and the softening of the cord. 

Etiology. — It is not a rare condition, but is most frequently seen as a 
complication of the infectious diseases. Chilling of the surface of the body 
seems to favor the development of this condition. Some authors state that 
it follows metallic or other chemical poisonings. It is frequently associated 
with spinal trouble, such as Pott's disease. Injury is frequently given as 
a cause, but syphilis is the most frequent cause. 

Pathology. — Macroscopical : The cord is seen thickened and sur- 
rounded by hyperaemic meninges. The substance of the cord is much 
softer than normal and sometimes resembles pus. Frequently small, punc- 
tate haemorrhages and even larger extravasations of blood can be seen 
microscopically. In severe disintegration of the cord, the microscopical 
findings are useless. It is in the mildest forms that pathological changes 
can best be studied. In the dilated blood-vessels we find leucocytes and 
granules of myelin. Corpora amylacea are frequently seen. 

Symptoms and Diagnosis. — The symptoms depend on, the portion of 
the cord tissue involved, and on the severity of the process. In syphilis we 
have a slowly developing condition weeks and months before myelitis 
symptoms pointing to this condition can be noticed. If children can 
complain they describe a sense of weight in the legs, which gradually 
increases, so that in a few days the limbs are entirely palsied. Convulsions 
and delirium have frequently been noted. When the reflexes are anatom- 
ically related to the affected segments they disappear, and below that level 
they are increased; after a few days, if the cord has been entirely de- 
stroyed at the inflammatory focus, the reflexes are entirely abolished 
(Church). Provided the posterior roots and meninges are involved, pain 
in the back and limbs is a prominent symptom, but rarely is of an ex- 
cruciating character at the onset. At the upper level of the inflammation 
some pain is the rule, which gives rise to a band or girdle sensation and a 
zone of hyperesthesia about the abdomen or chest. This sign, with the 
paralysis, definitely localizes the upper limit of the lesion, but if it be in 
the lower cervical region this sensation passes down the arms and is not so 
sharply defined. Lesions in the cervical region are also marked by impli- 
cation of the cilio-spinal center, .with consequent dilatation of the pupil. 



ACUTE MYELITIS. 7G5 

Continuous priapism is then, too, a usual occurrence, and the intercostal 
muscles and heart may be affected. Below the lesion, and depending upon 
its intensity, there are variations in sensibility to all forms of stimulation, 
from slight blunting to the usual complete anaesthesia. Sensations of 
drowsiness and aching in the paralyzed and anaesthetic limbs are some- 
times mentioned; and cramps and drawing up of the limbs frequently 
occur early, and later' are the rule. Distinct muscular atrophy related to 
the portion of the cord affected takes place, but in the trunk it is not 
readily discernible. The paralyzed limbs during the first few days are 
abnormally warm, but soon present a subnormal temperature; sluggish 
circulation and emaciation ensue, with oedema of the feet and legs if the 
limbs are left any length of time in a pendent position. If the lesion is low 
down, the atrophy is a marked feature and the reaction of degeneration is 
present. Under the influence of pressure, bed-sores form on prominent por- 
tions of the body and limbs, and this very early. In some cases within the 
first week immense sphacelation may take place over the sacrum, which 
cannot be explained by pressure and the moisture from the urine, but im- 
plies a dystrophic condition of cord origin. Trophic symptoms (bed-sores) 
are especially liable to occur when the lumbar cord is the seat of the disease. 

Prognosis and Course. — The course of the disease is chronic. The 
condition varies but little. The symptoms get worse and worse until death 
ends the trouble. From a few weeks to a few months may terminate the 
disease, 

At times if it is associated with or dependent on Pott's disease, im- 
provement may be expected. Sometimes myelitis is caused by syphilis 
either in its active form or due to a syphilitic neoplasm. It is rare in such 
conditions to effect a cure. 

Treatment. — If specific conditions such as syphilis exist, then anti- 
luetic treatment is required. Iodide of sodium can be given in very large 
doses, 5 to 50 grains per day. The general indications, such as attention to 
the stomach and bowels, must be met and stimulated if required. It is im- 
portant to feed a patient in this condition with very nutritious food. Coun- 
ter-irritation over the spine is advisable. For this purpose tincture of iodine 
or mustard will be useful. I insist on absolute rest in bed (water bed if 
possible) and in frequent change of position. 

Chkonic Myelitis. 

This condition is usually the continuation or the prolongation of acute 
softening of the cord. It is here that we find bed-sores as well as disturb- 
ances of the bladder and bowels. 

Treatment. — The treatment consists in what has been previously ad- 
vised in the acute condition. Life can only be prolonged by giving tone to 
the system with proper food. 



766 



DISEASES OF THE NERVOUS SYSTEM. 



Malformation of the Spinal Cord (Spina Bifida). 

The most frequent malformation seen is spina bifida. It affects the 
vertebral canal and ends in a protrusion of a small or large soft tumor filled 
with serum. This serum is a clear, yellowish liquid similar to cerebro-spinal 
fluid. We are indebted to Humphrey 1 for an accurate description of this 
lesion. He says : "Spina bifida is due to an early failure in development, 
in most cases before the cord is segmented from the epiblastic layer from 
which it is developed. Hence, it remains adherent to the epiblastic cov- 
ering, and the structures which should be formed between the cord and the 




Fig. 251.— Case of Spina Bifida. Spontaneous cure. Male child, 6 
years old. Now suffers with paralysis of both legs. Well nourished. No 
evidence of hydrocephalus. (Original.) 

skin are developed. For this reason we have in the wall of the sac a fusion 
of the elements of the cord, nerves, meninges, vertebral arches, muscles, and 
integument. If the error in development occurs later, the cord and nerves 
may be attached to the sac, but not intimately fused with it; in still other 
cases the cord does not enter the sac at all. The malformations may occur 
before the central canal is closed, or, if closed, it may reopen from the 
accumulation of fluid. It is probable that the accumulation of fluid first 
occurs^ and. that this prevents the union of the parts of the vertebral 
arches. 

"Although the tumor is generally associated with a bifid spine, this is 
not necessarily the case. The protrusion may take place through the inter- 



Lancet, March 28, 1885. 



HEREDITARY ATAXY. 7G7 

vertebral notch or foramen, or there may be a fissure of the bodies of the 
vertebrae, and an anterior tumor projecting into the cavity of the thorax, 
abdomen, or pelvis, spina bifida occulta. The principal anatomical varieties 
are meningocele, meningo-myelocele, and syringo-myelocele." 

The following case of spina bifida occurred in my private practice. A boy, 6 
years old, was brought to me with a history of having a very large growth in the 
lumbar region. The sac burst spontaneously. Since that time the boy has a double 
paralysis, and also suffers with incontinence of urine and faeces. He was brought to 
me for the treatment of the paralysis. The general condition was good and he 
appeared well nourished. There was no evidence of hydrocephalus. 

Treatment. — The treatment of spina bifida is surgical. I have seen 
a number of successful cases. 

Hereditary Ataxy (Friedreich's Disease). 1 

This condition is caused by degeneration . of the posterior columns 
of the spinal cord. As a rule several members of the family are affected. 

Etiology. — This disease is usually seen at or about the period of 
puberty. Measles, scarlet fever, or any other acute infectious disease may 
precede the development of this condition. 

Pathology. — The lesions seen are: "Sclerosis in the posterior columns 
(columns of Groll in their whole extent, and columns of Burdach in their 
upper part), in the direct cerebellar tract extending laterally into the column 
of Gowers, in the lateral columns (crossed pyramidal tract), in the gray 
matter (columns of Clarke, and posterior horns). In some cases dilatation 
of the central canal has been observed." 

Symptoms and Diagnosis. — The motor system shows the most charac- 
teristic symptoms. The patient stands with the feet far apart. The body 
sways and there is an unsteadiness while trying to maintain the equilibrium. 
The gait resembles that of an alcoholic intoxication. A tremor of the 
hands and head and choreiform movements affect the same parts. Paralysis 
and emaciation may be present. The tendon reflexes are absent as a rule, 
but their presence does not speak against the diagnosis in the early stage of 
the disease. The eyes show nystagmus. There is no optic atrophy. There 
is vertigo. The speech is slow. The intellect seems impaired. There is a 
peculiar clubbing of the feet. The foot is short. The toes are over- 
extended, the instep high and hollow. The Babinski phenomenon, or hyper- 
extension of the big toe, may be the first symptom of this condition. 

The prognosis is grave. The disease lasts years. 

Treatment. — The disease runs its course, although electricity and 
restorative treatment plus massage may be tried. The disease usually ends 
fatally. 



1 1 am indebted to Williams's excellent monograph for some points in this 
article. 



768 



DISEASES OF THE NERVOUS SYSTEM. 



Poliomyelitis (Infantile Spinal Paralysis). 

This disease is characterized by a sudden onset of fever, then paralysis, 
usually followed by muscular atrophy and imperfect bone development, 
sometimes by deformity. 

The recent studies of Flexner and Noguchi 1 show that poliomyelitis is 
due to a distinct micro-organism which can be isolated from the human 
poliomyelitic virus. The micro-organism exists in the infected and dis- 
eased organs ; it is not, as far as is known, a common saprophyte, or asso- 
ciated with any other pathological condition; it is capable of reproducing 
on inoculation the experimental disease in monkeys, from which animals 
it can be recovered in pure culture. Besides these classical requirements, 
the micro-organism withstands preservation and glycerination as does the 




Fig. 252. — M i ;ro-organism Causing Epidemic Poliomyelitis. Separate Globoid 
Bodies. X 1000. (Courtesy of Dr. S. Flexner.) 



ordinary virus of poliomyelitis within the nervous organs. Finally, the 
anaerobic nature of the micro-organism interposes no obstacle to its accept- 
ance as the causative agent, since the living tissues are devoid of free 
oxygen and the virus of poliomyelitis has not yet been detected in the cir- 
culating blood or cerebrospinal fluid of human beings, in which the oxygen 
is less firmly bound, nor need it, even should the micro-organism be found 
sometimes to survive in these fluids. 

Now that the specific cause of infantile paralysis has been found, it is 
but rational to assume that a specific serum or vaccine will be made, such 
being possible, we may then hope, with specific treatment in the pre- 
paralytic stage, to prevent the paralysis. 

Childhood is the age most susceptible to an infection of poliomyelitis. 
During the epidemic of 1916, New York City had over 9000 cases. The 
death rate was about 26 per cent. Connecticut and Maine each has nearly 
700 cases, New Jersey about 3500 cases, Pennsylvania about 1300 cases, 
and New York State, exceluding New York City, about 2800 cases. 



1 Journal of Experimental Medicine, vol. xviii, No. 4, 1913. 



POLIOMYELITIS. 



7G9 



Pathology. — One of the facts now established is that the inflammation 
of the cord is always accompanied by an inflammatory process in the pia 
mater. The pathological process in the cord itself is primarily dependent 
upon vascular changes, and secondarily, upon changes in the cells, both 
ganglionic and interstitial. The vessels of the cord, medulla, pons, basal 
ganglia, and even the cerebral cortex are dilated and engorged, and in the 
cord, medulla, and pons the capillaries are distended to more than twice 
their normal caliber. This hyperemia is found at all levels of the cord 
irrespective of the intensity of the other inflammatory changes. It is now 
firmly established that the pathological process in acute poliomyelitis is one 
which is primarily dependent upon the vascular and interstitial tissue 
changes and that the ganglion cells are secondarily affected. (I. Strauss.) 



1 — # 




Fig. 253. — Poliomyelitis. Sclerosis and cicatricial atrophy of the left 
anterior horn of the fourth cervical nerve after acute anterior poliomyelitis. 
(a) Normal anterior horn with ganglion cells. (6) Atrophic anterior horn. 
( Ziegler. ) 



According to Peabody, Draper, and Dochez, "These three facts, cellular 
exudate, haemorrhage, and edema, . . . may perhaps be regarded as the 
primary reaction of the nervous system to the virus of poliomyelitis." 
"... the damaging effects can be assumed to result in part from the 
direct pressure on the nerve cells of haemorrhages, edema, and exudate." 
These observations were made at autopsies. 

Symptoms and Diagnosis. — From a study of the epidemic prevailing 
during the summer of 1916, the following classification seems justifiable : — 

First. The Abortive Type. — These are the cases responsible .for the 
spread of the disease, for the large majority, owing to the mildness of their 
symptoms, are passed unnoticed. They may be termed the "carriers" of 
this infection. 

The temperature may rise no higher than 101 and last but one or two 
days. The child will be apathetic, complain of headache, and have extreme 



4Q 



770 DISEASES OF THE NERVOUS SYSTEM. 

lassitude. He may also complain of pain in the arms and legs. In some 
forms of the abortive type the symptoms will pass after one day, the child 
will regain his appetite, and be as bright as usual. The reflexes may be 
slightly exaggerated, but there are no other evidences of paralysis. 

Second. Gastroenteric Type. — In this type we have vomiting, ano- 
rexia, fever ; temperature ranging between 102 and 105 degrees, pulse rang- 
ing between 100 and 140, extreme lassitude, pain on moving the arms or 
legs, pain in the back of the neck, headache, and a general apathetic condi- 
tion. The sclera of both eyes show engorged blood-vessels, the eyes stare 
or are fixed, the pupils respond slowly, the patellar reflexes are exaggerated 
or are lost, the child appears to be in a stupor or semicomatose condition, 
usually followed by paralysis. 

Third. Respiratory Type. — In the milder forms of this type we have 
symptoms resembling rhinitis with fever ranging between 102 and 104 
degrees, cough, peevishness, restlessness, and general prostration. In the 
severer forms we have symptoms resembling bronchopneumonia : high fever; 
shallow, frequent respirations ranging between 50 and 80 per minute, pulse 
of 130 to 150 per minute, extreme lassitude, weakness or absence of knee- 
jerk, and evidences of profound toxaemia. Paralysis of the respiratory cen- 
ters frequently follows. 

Fourth. Bulbar Type. — In the bulbar type we have inability to swal- 
low or speak, marked rigidity of the sternocleidomastoids, with intense pain 
in the head and neck, moaning usually preceded by convulsions, both tonic 
and clonic in character. The muscular system of the arms and legs show 
intense rigidity. The Kernig sign is sometimes present, and more fre- 
quently marked hyperextension of the big toe (Babinski) is noted. The 
pupils respond sluggishly and are unusually contracted. All the symptoms 
of a meningitis, such as a tache cerebrale and Brudzinsky's sign described 
elsewhere are present. In the early stages the patellar reflexes may be 
slightly present, but later are absent. The plantar reflex is usually present. 
The cremaster reflex slightly present. Paralysis usually takes place after 
the febrile condition subsides. The duration of the fever is from three to 
six days, although I have seen cases in which the fever persisted ten days. 

Preparalytic Symptom. — During* the febrile stage, if the child is care- 
fully observed, we can frequently note an important symptom which has 
been described by Colliver 1 as a preparalytic symptom. It is a peculiar 
twitching, tremulous or convulsive movement. It usually affects a part of 
whole of one or more limbs, the face or jaw. It may also affect the whole 
body. In the beginning the symptoms may last less than one second, and 
may not recur oftener than every hour or so. Later the spells lengthen to 
a few seconds, and recur at shorter intervals. The condition is sometimes 



1 Journal of the Amer. Med. Assoc., March 15, 1913. 



POLIOMYELITIS. 771 

accompanied by a peculiar cry, similar to the hydrocephalic. During the 
convulsive movement the child is apparently unconscious, with eyes set for 
a few seconds. A similar symptom has been described by Professor Netter, 1 
of Paris. This preparalytic symptom, if noted, will serve as a warning of 
the approaching paralysis, and when observed, the limb should be strength- 
ened by support. 




Fig. 254. — Paralysis of the muscles Fig. 255. — Paralysis of the spinal 

of the back, trunk, and neck. Cannot muscles. Intercostals, showing in- 

sit unsupported. (Original.) volvement of the serratus magnus. 

(Original.) 

Eruption. — In many cases a pin-point erythema (scarletiniform) scat- 
tered over the chest, abdomen, and flexor surfaces of arms was seen. Some- 
times the rash appears as urticarial blotches or wheals, principally on 
abdomen, back, thighs, and arms. In these cases toxic, gastric, or gastro- 
enteric symptoms are found. Another type of eruption seen is the mor- 
billiform type. The eruption crescentic in character is found on face, neck, 
thorax, and a few scattered areas are seen on the arms and legs. The erup- 
tion usually lasts from three to ten days, and fades with the fever. 



1 British Jour, of Children's Diseases, Dee., 1913. 



772 DISEASES OF THE NERVOUS SYSTEM. . 

Lumbar puncture 1 should be made to verify the diagnosis. Fifteen to 
25 cubic centimeters of spinal fluid should be withdrawn. If the fluid 
comes out under great pressure, then 50 to 100 cubic centimeters may be 
withdrawn. 

According to the findings of the New York Board of Health/ the 
spinal fluid in poliomyelitis is usually clear and increased in amount. The 
albumin and globulin are increased in varying degrees, and there is usually 
a good reduction of Fehling's. The cellular increase ranges from slightly 
above normal to over 900 cells per cubic centimeter. Early in the disease 
the cells may be 50 per cent, or more mononuclears. Later there is usually 
90 per cent, or more mononuclears. There are frequently large mononu- 
clear cells that seem somewhat characteristic of these fluids. 

Treatment. — Through the needle left in situ Meltzer advises the injec- 
tion of 2 c.c. of a 1:1000 adrenaline solution. The adrenaline injection 
may be repeated every four hours during the first day, and if improvement 
is noted, every six hours, and later every twelve hours on successive days. 

Muscular rigidity, accompanied by pain, is best relieved by warm sul- 
phur baths. The crude sulplmret of potassium, 4 ounces to a tub bath at 
a temperature of 103°, will frequently relax the body and promote sleep. 
In some cases it will be found necessary to prolong the bath fifteen to 
twenty minutes to produce an effect. These baths should be given morning 
and evening for at least one week. 

Serum Treatment. — Fifteen cubic centimeters of blood serum from a 
convalescent or immunized case of poliomyelitis should be injected intra- 
spinally by the gravity method as soon as procured. 3 One injection of 
serum is usually sufficient, although the same dosage may be repeated in 
twenty-four hours if no improvement is noted. I have used intraspinal 
irrigations of normal saline solution at a temperature of 110° to 112° in a 
series of cases with excellent result.' Several moribund cases responded 
promptly to this form of treatment. The needle is introduced between the 
fourth and fifth lumbar vertebras, and as much as possible of the spinal 
fluid withdrawn. Thirty to 100 cubic centimeters have been withdrawn at 
one time. After draining, 30 cubic centimeters of the saline solution is 
injected. This is repeated three times. After the third drainage, 15 cubic 
centimeters of blood serum from a convalescent case is injected, the needle 
withdrawn, and the puncture sealed with a drop of collodion or medicated 
adhesive plaster. 



1 The technique and illustration of lumbar puncture is described on page 789. 

2 Josephine B. Neal, Archives of Pediatrics, August, 1916. 

3 This method was advocated by Dr. A. Zingher, of the New York Board of 
Health, Research Department, during the epidemic of 1916. I have had excellent 
results with the same. 



POLIOMYELITIS. 



773 



In the bulbar type with extreme prostration and coma, where it was 
impossible to feed by month, I have used injections of warm saline solution, 
250 cubic centimeters, every four to six hours, by hypodermoclysis. In one 
case of coma with inability to swallow the child received 250 cubic centi- 
meters of saline solution in the loose cellular tissue of the abdomen with 
excellent results. Hot saline colonic flushings at a temperature of 110° to 
115° were given to supplement the hypodermoclysis. 





Fig. 256.— Paralysis of the left leg and foot. Typical drop-foot. Note 
position of the foot in standing — due to paralysis of the quadriceps muscles. 
( Original. ) 



In older children "muscle training" is commended and the child 
guided through active exercises, so that atrophy from non-use is prevented. 

A comparison of this latter method of muscle active treatment, rather 
than the muscle passive treatment, which latter results from splints, braces, 
and plaster casts, shows a decided leaning toward the muscle active treat- 
ment. Patience and persistence will be rewarded, by success after weeks 
and months of this treatment. The child's brain must, be in sympathy 
with its movements; hence, the passive exercises," such as gymnastics or 
massage, are far inferior to a method by which the child can be instructed 
in the performance of various exercises in which the boctjwahd mind 



774 DISEASES OF THE NERVOUS SYSTEM. 

co-ordinate. It has been found by clinical experience, and such cases have 
been reported by Teschner and others, that a muscle, be it ever so atrophied, 
can be redeveloped by a system of carefully planned exercises. Electricity 
or galvanic current may be used in conjunction with massage, but gentle 
massage will accomplish just as much, and more than violent rubbing by 
inexperienced hands. 

Medicinal Treatment. — Intramuscular or intravenous injections of 
one-half the usual dose of salvarsan given as a restorative may be tried. 
The dose should be repeated every week until the systemic effect of the sal- 
varsan is manifested. Intramuscular injections of strychnine in doses 
°f Vioo grain every other day gradually increased until 1 / 50 grain can be 
given to a child 5 years old, younger children in proportion. Arsenic in the 
form of Fowler's solution may be given in doses of 1 to 5 drops three times 
a day. 

The treatment must be directed toward elimination of toxin as much 
as possible. Urotropin (which liberates formaline) may be given in 2- to 
3- grain doses several times a day. Hot packs over the affected parts have 
a stimulating tendency. 

Restorative treatment should consist in giving concentrated food, such 
as milk, yolk of egg, broth, and gruel. Seabaths will aid in restoring normal 
conditions. The treatment must be persisted in for months. 

Prevention of Drop-foot. — When it is evident that a group of muscles 
is weakened, a support is necessary. Tubby says that recovery is always 
hindered and even entirely prevented in a stretched muscle, whereas when it 
is relaxed the reverse is the case. Therefore, in order to obtain the best 
result in an affected muscle, relax it to its fullest extent and massage it. 

Elongated muscles are earliest restored to power and use by maintain- 
ing them slack. Muscles not paralyzed will contract. George W. Jacoby 
recommends, as a prophylaxis for drop-foot, placing the foot in rectangular 
position by means of bandages and splint to prevent contracture. Never 
even allow the weight of bed clothes on the foot. 

In cases of drop-foot or drop-wrist, tenotomy may be required, but 
this should be left to the judgment of a conservative orthopaedist. Muscle 
transplantation is advised after paralysis is firmly established. 

Erb's Palsy. 

This is commonly known as obstetrical paralysis, and is caused by 
pressure exerted on the brachial plexus during birth. One or both arms 
may be involved. 

Brachial plexus paralysis is amenable to treatment. An interesting 
case of this kind occurred in the practice of Dr. D. P. Waldman, of this 
city, with whom I saw the case in consultation. The infant was born after 



CHRONIC INTERNAL HYDROCEPHALUS. 



775 




Fig. 257.— Case of Chronic Internal Hydrocephalus. Note the position 
of the eyes and the globular shape of the head. Aspiration of the ventricles 
every week gave 50 to 60 cubic centimeters of a perfectly clear fluid. 
(Original.) 




Fig. 258. — Front view of same case. Note position of eyes and ears. 
This is a characteristic expression of hydrocephalus. (Original.) 



776 DISEASES OF THE NERVOUS SYSTEM. 

an unusually protracted labor with complete unilateral paralysis involving 
the right arm. With the aid of general manipulation and faradic elec- 
tricity the case completely recovered. The duration of the attack was, from 
onset to cure, about three months. 

Treatment. — The treatment, as a rule, consists in using gentle massage 
daily ; also a mild faradic current every other day. If there is no response 
to this treatment within ten days the galvanic current should be tried. Tub 
baths at temperaure of 102° F. duration one minute should be given prior 
to each massage. 

Hydrocephalus. 

This is an accumulation of serum in the head. 

External Hydrocephalus. — When the effusion is between the dura 
mater and the pia. 

Internal Hydrocephalus. — When the lesion is in the ventricles of the 
brain. The latter condition is most commonly seen. 

Acute Hydrocephalus. 

This condition usually follows basilar meningitis. In acute hydro- 
cephalus the effusion is not large. Some authors state that no more than 
three or four ounces of serum are present. 

Chronic Internal Hydrocephalus (Water on tlje Brain). 

This condition must not be confounded with tubercular meningitis. 

Etiology. — The cause of primary or secondary internal hydrocephalus 
is very difficult to determine. In some instances syphilis has been given as 
the causative factor. An interesting paper has appeared by D' Astros, 1 
who describes 12 cases in which hydrocephalus was associated with syph- 
ilitic lesions, so that the condition was congenital. By some, chronic hy- 
drocephalus is believed to be due to tuberculosis. 

Pathology. — "The changes in the brain result from the gradual accu- 
mulation of fluid in the ventricles. The septum lucidum is usually broken 
down, and all the avenues of communication between the ventricular cav- 
ities are greatly enlarged. The continuous distention results in a gradual 
thinning of the brain substance which forms the ventricular walls; often 
these are found only one-fourth of an inch in thickness, or even less than 
this, the cortex being a mere shell." 

The brain appears anaemic, so that the gray and white substances re- 
semble each, other. The bones of the skull show the lesions very plainly. 
The sutures are separated in some cases. Where premature ossification has 
taken place, the head instead of being very large, is very small. This is 
called a microcephalic condition. Sometimes spina bifida is associated with 
this condition. 



Revue Mensuelle des Maladies de 1' Enfance, Chapter IX, pp. 481 and 543. 



HYDROCEPHALUS. 



777 



Symptoms. — The first symptoms that attract attention are, that the. 
head is increasing in size; that it seems very heavy; that the child appears 
stupid; that it does not notice things, but stares continuously. The fore- 
head is very high, the fontanel distended and bulging. On palpating, the 
soft fluctuating liquid can be' felt. The sutures are very wide apart. The 

pupils are usually enlarged, some- 
times contracted. Convulsions are 
frequently present. While the head 
enlarges the body emaciates. 

Prognosis and Course. — This dis- 
ease usually terminates fatally about 
the seventh year. In rare instances 
the condition may extend through life 
with impaired mental faculties due to 
the brain trouble. Cases that have 
been reported cured should be viewed 
with suspicion. 

Treatment. — Aspiration has been 
tried by many, with no apparent bene- 
fit. I have never seen a good result 
follow the aspiration of the liquid, be- 
cause the fluid returns very rapidly, 
so that nothing is gained by the 
operation. 

Blistering, counter-irritation, 
strapping, and lumbar puncture have 
been tried by me with no apparent 
success. Iodoform collodion has been recommended by some. 

In a case seen in consultation with Dr. L. Harris, of tliis city, convulsions were 
relieved by lumbar puncture. 

Mercurial inunctions and large doses of iodide have been tried. If 
syphilis is the cause, then some benefit may be expected from specific 
treatment. 

Meningocele. 

When there is defective ossification in the bones of the skull and some 
part of the membranes of the brain protrudes, it is 'called a meningocele. 
Some writers believe it is caused by an intra-uterine hydrocephalus. These 
tumors generally contain cerebro-spinal fluid in the bag of membrane. 
When pressure is exerted over the swelling, the liquid will be emptied into 
the brain. Sometimes cerebral symptoms will result from this mani- 
festation. 

Encepiialocele {Cerebral Hernia). 

In this condition there is a protrusion of the brain substance in addi- 
tion to the membrane. This protrusion takes place through the frontal and 




Fig. 259. — Hydrocephalic cal- 
varium (or skull-cap), widely gaping 
fontanels and sutures. One-half 
natural size. (Langerhans.) 



778 DISEASES OF THE NERVOUS SYSTEM. 

occipital bones. It is usually a congenital deformity. If the tumor con- 
tains a portion of a dilated ventricle and is filled with cerebro-spinal fluid, 
it is called a hydro-encephalocele or hydro-encephalo-meningocele. 

A case of this kind was seen by me some time ago in which the tumor protruded 
through the occipital bone. It was a congenital deformity. Distinct pulsation could 
be felt. The tumor increased in size when the child cried. Convulsions resulted from 
forcibly pushing the tumor into the cranial cavity. 



Fig. 200. — Encephalocele. Infant 1 day old, admitted to my hospital 
service, having a globular tumor in the occipital region of the head. The 
tumor measured S 1 /^ centimeters from above downward, and 8% centimeters 
from side to side. The autopsy was performed by Dr. John Larkin. 
(Original.) 

Treatment.— The injection of 1 drachm of Morton's fluid after aspira- 
tion of some of the liquid contents may be tried. Morton's fluid : — 

1$ Kali iodide 30 grains 

Iodine pure 10 grains 

Glycerine 1 ounce 

M. Inject 1 drachm after each aspiration. 

If no improvement is noted after some time, surgical treatment should 
be tried. 

Cyclops. 
This is a very rare condition and consists of the child having but one 
orbit, which is situated in the middle of the forehead at the root of the 
nose. 

Porencephaly. 

This consists usually of a defective development, leaving a hole in the 
brain. It is a congenital disease and may be located in any portion of the 
brain. 



CHAPTEE IV. 
TUBERCULAK MENINGITIS (BASILAR MENINGITIS). 

This is usually a secondary condition. It is not a primary disease of 
the meninges. In infants, tubercular meningitis usually follows bone tu- 
berculosis, tuberculosis of the lymph nodes or joints, and not infrequently 
a tubercular otitis may extend and involve the meninges. 

Etiology. — The association of adenoid vegetation and the probable 
entrance of the tubercle bacillus through the lymph channels of the neck 
is the most probable means of infection. 1 (See article on "Acute Tubercu- 
losis.") 

Bacteriology. — There is no question about the association of the 
tubercle bacillus with this infection. It can be found in the spinal fluid 
withdrawn by a lumbar puncture. Other pathogenic bacteria may also be 
found. In one case reported by me we found the diplococcus intracellularis 
in addition to the tubercle bacillus. 

Pathology. — The chief pathological condition is a growth of miliary 
tubercles. Associated with these we frequently find tubercular nodules of 
variable size, and in almost every case they are the products of ordinary 
inflammation of the pia mater — lymph or pus — together with an accumu- 
lation of fluid in the lateral ventricles of the brain. Holt says : "Frequently 
there are tubercles in the pia mater of the upper portion of the cord. The 
miliary tubercles appear as small gray or white granules, situated along the 
vessels of the pia mater. When few in number they are usually located at 
the base, especially along the Sylvian fissures and in the interpeduncular 
space. When numerous, they are most abundant at the base, but are also 
seen scattered over the convexity in small groups. In about half of my 
autopsies they have been limited to the base, and in no case were they seen 
exclusively at the convexity. Tubercles are often found in the choroid coat 
of the eye. The amount of lymph and pus present is rarely great, and 
never equal to that seen in simple acute meningitis. It is often a matter 
of surprise at autopsies to find the lesions so few, after very marked symp- 
toms. The inflammatory products are most abundant at the base. In addi- 
tion to the patches of greenish-yellow lymph, there are adhesions between 
the lobes of the brain and thickening of the pia. In cases which have lasted 
for several weeks, the pia mater in places is often very much thickened, 



1 This view is maintained by W. Freudenthal, of New York. 

(779) 



780 



DISEASES OF THE NERVOUS SYSTEM. 



owing to cell infiltration and the production of new connective tissue, and 
it is studded with miliary tubercles, sometimes with small }^ellow tuber- 
culous nodules; frequently there is arteritis, which is sometimes obliterat- 
ing. 

"In the most acute cases the brain substance immediately beneath the 
pia is intensely congested, slightly softened, and shows under the micro- 
scope a superficial encephalitis. The lateral ventricles are usually distended 
with clear serum, sometimes with serum containing flocculi of lymph or 




V " a 1> c d 

Fig. 261. — Tuberculous Spinal Meningitis. Longitudinal Section of 
Spinal Cord and Posterior Roots, {a) Spinal cord; (6) pia mater; (c) 
subarachnoidal space; (d) arachnoid; (c) posterior roots, cellular infiltra- 
tion and containing isolated swollen axis cylinders; (f) vessel with cellular 
infiltration and proliferated wall; {g) cellular exudate in subarachnoidal 
space; [i) swollen axis cylinder. X45. (Ziegler.) 

pus; the amount present varies from one to four ounces in each ventricle, 
being always greater in the subacute cases. The walls of the ventricles may 
be softened. The distention of the ventricles leads to flattening of the 
convolutions from pressure against the skull, to bulging of the fontanel, 
and sometimes to separation of the sutures, if they are not completely ossi- 
fied." 



PLATE XXXVII 




Disseminated Pulmonary Tuberculosis in a TAvo-year-old Child having Tubercular 
Meningitis. (Courtesy of Dr. Wm. H. Stewart.) 



TUBERCULAR MENINGITIS. 781 

Tuberculous nodules varying in size from a small pea to a walnut are 
frequently seen associated with meningitis in older children, but not so 
'often in infants. These nodules may be connected with the meninges, or 
they may be situated within the brain substance, usually in the cerebellum. 
The larger ones are classed as brain tumors. Inflammatory products are 
rarely found in the spinal canal. 

Course. — The course of tubercular meningitis is from three to ten 
days, although the symptoms may last from four to eight weeks, or even 
longer. 

Child B. W., 5 years old. Father a physician and healthy. Mother healthy. 
Had just returned from the country in apparent good health. Was sent to school 
and seemed bright mentally and physically. Was a well-nourished child. Had 
had no previous illness excepting a disordered stomach. The first symptom of her 
present illness was headache. Had a coated tongue, loss of appetite and a slight rise 
of temperature, from 100° to 101° F. The temperature was very characteristic. (See 
chart.) The parents suspected a slight dyspeptic attack and gave her a laxative. 
Her diet was also corrected. In spite of cleansing the stomach and bowels, the 
headache persisted and reached such an acute stage that the child cried and moaned 
continuously, and did not sleep. When I first saw the case the symptoms of an 
acute gastric catarrh were so evident that nothing further was suspected. The 
headache persisted in spite of bromides. The child complained of ringing in the 
ears. Had twitchings of the arms and legs. The bowels assumed a normal color 
and consistency. An examination of the eyes with the ophthalmoscope was first 
made by Dr. H. Jarecky and later by Dr. Henry S. Oppenheimer, who found vision 
good, no choked disk — engorgement of veins only — -slight reaction of pupils. No 
evidence of tubercular disease was found. In the beginning of this illness the 
symptoms of headache were very prominent. The child appeared quite rational and 
the diagnosis of supra-orbital neuralgia was made. Dr. George W. Jacoby, who saw 
the case at my request, early in the disease believed that we were dealing 
with meningitis. Later on, however, the symptoms were positive. Dr. Abraham 
Jacobi, who saw this case later in consultation, diagnosed meningitis. At his 
suggestion leeches were applied and they afforded quite some relief. The head- 
ache reappeared with renewed vigor and remained incessant throughout the 
period of illness. Owing to the continued pain it was decided to relieve the intra- 
cranial pressure by lumbar puncture. I aspirated 45 cubic centimeters of clear spinal 
fluid, which was sent to Dr. Billings, of the New York Health Department, for 
examination. He reported the presence of the tubercle bacillus and the diplococcus. 
Dr. B. Sachs confirmed the diagnosis of tubercular meningitis. 

Strabismus was also present. There was marked facial paralysis. Nausea and 
vomiting occurred. There were spasms and twitchings, also a haemiplegic paralysis. 
There was also a unilateral flush on the cheek and other well-marked evidences of 
vasomotor disturbances. The child was either soporose, in a semi-stupor, or crying 
and screaming with pain in the head. A distinct red streak remained when the skin 
was stroked with the finger nail, the so-called tache cerebrale. The Babinski reflex 
was also present. There was spastic rigidity of the entire body. The eyes were 
half open. Respiration was labored, at times— Cheyne-Stokes respiration. The 
pulse was small and compressible and varied between 80 and 160. The child died of 
extreme exhaustion and inanition, after suffering about ten days of terrible agony. 



782 



DISEASES OF THE NERVOUS SYSTEM. 



Symptoms and Diagnosis.— An irregular and intermitting pulse with 
Cheyne-Stokes respiration and slight elevation of temperature are amongst 
the early symptoms of this disease. The pupils show irregularity ; not in- 
frequently one pupil will be dilated, while the other may be a pin-point. 




-Case of Tuberculous Meningitis, well marked, 
ending fatally. (Original.) 

Vomiting is an early symptom in many cases, and may continue in spite of 
rigid supervision of the diet, so that an organic lesion will be suspected. 
The vomiting is usually projectile in character. Later in the disease, the 
temperature ranges from 100° to 103° or even higher. The pulse may 



TUBERCULAR MENINGITIS. 783 

vary between 80 and 160 beats per minute. The respirations are increased 
and irregular in character, labored or sighing. 

Tache Cerebrate. — The tache cerebrale is frequently* present. This is 
produced by drawing the finger-nail quickly over the skin of the abdomen, 
arm, or leg, when a sharp, bright mark remains for several minutes. 

Some symptoms come on very slowly. Intense headache is complained 
of and is usually supra-orbital in character. In the case referred to in this 
chapter the symptoms were masked for a number of days. The eyes usually 
show tubercles in the choroid. In the case reported here, although the eyes 
were examined by two competent oculists, no evidence of disease could be 
found. Strabismus as well as facial paralysis are frequently seen as evi- 
dence of paralysis. Twitchings are frequently noticed. 

The Babinski reflex is very often present. 

The child sleeps with its eyes half open. There is marked evidence 
of vasomotor disturbance, such as unilateral flushes, and spastic rigidity of 
the entire body is repeatedly seen. 

Lumbar 'puncture will usually show a clear cerebro-spinal fluid. In 
this fluid the tubercle bacilli can be located. In some cases other pathogenic 
bacteria — for example, the streptococcus — can be found. 

Inoculation of skin with tuberculin — von Pirquet test — is helpful in 
making the diagnosis. 

The prognosis is bad. I do not know of a single case of distinct tuber- 
cular meningitis that finally recovered. 

Treatment. — Lumbar puncture should in all cases be performed. For 
details regarding technique of lumbar puncture see chapter on "Epidemic 
Cerebro-spinal Meningitis." Tapping the fourth or fifth ventricle will 
certainly relieve intra-cranial pressure. No more than 15 to 25 cubic cen- 
timeters should be withdrawn at one aspiration. I look upon this as a very 
valuable diagnostic as well as therapeutic measure. The head should be 
shaved, and an ice-bag or ice-coil applied continuously. Next in impor- 
tance several leeches should be applied behind the ears, over the mastoid 
process of the temporal bone. Cerebral engorgement can also be relieved by 
applying leeches to the alae nasi; this will drain the blood through the 
frontal sinus. Eectal medication should be remembered. 

Large doses (5 to 10 grains) of sodium bromide and sodium iodide 
should be given until quiet is insured. The bowels should be cleansed by 
a thorough irrigation with glycerine and water. Iodoform collodion (10 
per cent.) can be applied to the scalp, thoroughly, once or twice. 

Inunctions with unguentum Crede or mercurial ointment, at the nape 
of the neck, rubbed into the lymphatics, for at least twenty minutes several 
times a day, will frequently do some good. 

Peptonized milk, whey, soups, broths, zoolak, and buttermilk are indi- 
cated. Under no conditions should solid food be administered. If the 



784 DISEASES OF THE NERVOUS SYSTEM. 

child is in a coma, rectal feeding must be resorted to. (For details see 
chapter on "Eectal Feeding.") 

Cerebrospinal Meningitis (Acute Meningitis, Spotted Fever, or 
Malignant Purpuric Fever). 

Cerebro-spinal meningitis is an acute infections disease characterized 
by a sudden onset of symptoms. 

Bacteriology and Etiology. — The presence of the diplococcus intra- 
cellularis of Weichselbaum is usually the causative agent of this disease. In 
a few cases, streptococci ; in others, pneumococci have been found. 

Weichselbaum states that he believes the meningococcus is frequently 
present and lies dormant in the crypts of the tonsils and pharynx. For 
this reason he believes that, when a lowered vitality exists clue to subnormal 
conditions, then the meningococcus gains access through the lymph channels 
to the meninges and sets up an acute and sudden infection. In addition 
to the presence of the meningococcus in the tonsils, this pathogenic microbe 
is frequently found in the nose from whence it probably gains access through 
the frontal sinuses and reaches the brain. The meningococcus can be trans- 
mitted and an infection disseminated by direct contact with infected secre- 
tions containing the diplococcus intracellularis. Weichselbaum does not 
believe that the sudden appearance of a case of cerebro-spinal meningitis, 
in an otherwise healthy locality, is extraordinary when the etiological con- 
ditions, such as the possibility of harboring this diplococcus in the nose and 
throat, are remembered. 

Pathology. — In the early stage of this disease we note hypersemic 
conditions in the brain and spinal cord. When the disease has progressed, 
the arachnoid appears cloudy, especially along the course of the blood- 
vessels from which a purulent exudate oozes. This purulent exudate in- 
volves all the tissues of the convexity and frequently extends to the base in 
the meshes of the pia and between it and the cortex. The fluid in the 
ventricles is as a rule increased, and may contain small nocculi of fibrin. 
Haemorrhage is frequently noted in this region. The joints show evidences 
of septic inflammation. The spleen is frequently enlarged. Evidences of 
infection and sepsis are present in all parts of the intestinal organs of the 
body. Multiple abscesses may occur, and not infrequently parenchymatous 
degenerations involve the kidneys, liver, and spleen. 

Purpuric spots or mottling, so frequently seen on the outside of the 
body, may sometimes be seen more distinctly in the internal organs. 

Climatic Conditions. — The greatest number of cases occur during the 
winter months, while sporadic cases are seen in the spring, summer, and fall 
months. 



PLATE XXXVIII 



«? 



"1* * 






4 



^ ft* ^ 









*U"* 



^Meningococci in Pus-cells, Spinal Fluid. Characteristic Intracellular 
Arrangement. 



CEREBROSPINAL MENINGITIS. 



785 



Table No. 77 .—Deaths from Ccrebro- Spinal Meningitis in Children under 
15 years. New York City— 1902-1907. 



Year. 


Old New York City. 


Greater New York City. 


1902 


156 


221 


1903 


158 


225 


1904 


805 


1056 


1905 




2775 


1906 




1032 


1907 




828 



Symptoms. — During the epidemic there were three classes of cases 
encountered: first, a mild type; second, a severe type; and third, an 
abortive type. 

Mild Type. — In this class of cases there is a slight rise of temperature, 
generally malaise, and perhaps vomiting. 

Abortive Type. — This type is usually seen in strong children who are 
able to withstand a severe infection. By reason of their health they are 
infected in a lesser degree, as shown by their symptoms and the rapidity of 
their convalescence. The onset is usually sudden, and I have seen meningeal 
symptoms subside within ten days with no sequehw This happened in a 
case of a child with undoubted cerebrospinal meningitis, in which the 
diagnosis was confirmed by the bacteriological examination of the spinal 
fluid. Ehinitis with catarrhal discharge from the nose is sometimes an 
early symptom in this disease. Ehinitis is frequently found in the abortive 
type of the disease. The danger of having the meningococcus in the nose 
consists in the ease with which this pathogenic bacterium can enter the 
frontal sinus and thus give rise to encephalitis. In the abortive type of this 
disease there frequently is a nasal discharge in which the meningococcus 
intracellular is can be found long after the rhinitis has disappeared. The 
ambulatory cases are the ones which disseminate this infection because they 
carry the pathogenic bacteria from house to house. 

Severe Type. — In the severe type there is a sudden onset of symptoms. 
In older children a distinct chill is usually the first symptom noted. The 
skin feels hot. The temperature rises anywhere between 102-105° F. (38.8 
and 40.6° C), in the rectum. The pulse varies; it may be slow or very 
rapid. The respiration is irregular in character, sometimes sighing, and 
labored, but most frequently Cheyne-Stokes in character. Later on there is 
vomiting, pain in the head, in the frontal or occipital regions, and pain at 
the back of the neck. There is moaning and frequently delirium. Vaso- 
motor disturbances, such as the flushirg of one ear or one cheek, are 



786 DISEASES OF THE NERVOUS SYSTEM. 

occasionally seen. The tache cerebrate is usually noted when stroking the 
breast with the finger nail, as a distinct hyperemia follows and remains for 
several minutes. The tendons are very sensitive to the' slightest pressure. 
The patellar reflexes are usually absent. When the thigh is flexed on the 
abdomen and we try to extend the leg there is considerable latent contraction, 
the so-called Kernig sign. This symptom alone should not be depended 
upon. Hyperextension of the big toe produced by stroking the sole of the 
foot, the so-called Babinski reflex, is not always present. It is also fre- 
quently noted in perfectly healthy children. In a series of fifty children 
examined by me, the Babinski reflex was found in forty. 

Brudzinski's neck sign in tuberculous and other types of meningitis is 
present in 100 per cent, of those ill with either cerebrospinal meningitis, 
serous or pneumococcous meningitis. 

Technique to Elicit Neck Sign. — The head is forcibly flexed with the 
left hand while the child is lying flat on its back; with the right hand, 
pressure is exerted on the chest to keep the child from being lifted. If the 
sign is positive, both legs will flex on the thighs and the thighs on the 
abdomen. 

The identical collateral sign consists in flexing the leg on the thigh 
and the thigh on the abdomen, when the opposite lower member will assume 
the same position. 

The normal cytology of the cerebrospinal fluid varies from to about 
7 lymphocytes per cubic millimeter. In any meningeal irritation, acute or 
chronic, the lymphocytes increase in number. They may be increased in- 
definitely up to thousands. 

In a number of cerebrospinal fluids from infants, examined by Kaplan, 
he found that in the tubercular forms the tymphocytes predominate. In 
the other acute meningitides of children the polynuclears and lymphocytes 
claim about equal or nearly equal relations. It is marvelous how readily 
the polynuclears diminish if the case shows the slightest tendency to 
improve, and, vice versa, they increase as the inflammatory process grows 
worse. Pari passu with the polynuclear increase the Fehling reaction 
disappears. This point is extremely important, as there are a number of 
cases of tubercular meningitis where the tubercle bacillus cannot be found 
even if the antiformin or the Jousset method is used. In these instances 
I consider the copper-reducing substance in the cerebrospinal fluid as highly 
suggestive of the tubercular nature of the meningitis. The non-reduction 
of the Fehling solution or the appearance of a violet color change instead, 
in Kaplan's opinion, is significant of the non-tubercular nature of the 
affection unless a mixed infection is at hand. In case a double infection is 
demonstrated microscopically, the invader that has the upper hand in the 
infection usually reflects upon the behavior of the cerebrospinal fluid with 
the Fehling solution. If it is the tubercle bacillus it will reduce; if it is 



PLATE XXXIX 





Cerebrospinal Meningitis. Autopsy showed a yellowish-green, muco- 
purulent exudate, cheesy in character, covering the anterior two-thirds 
of the cerebrum. The fluid obtained by lumbar puncture as well as that 
by intraventricular aspiration showed a pure influenza bacillus. The 
autopsy was performed by Dr. John Larkin. The fluid examined by Dr. 
Sophian and Dr. M. D. Kaplan. 



CEREBRO-SPINAL MENINGITIS. 787 

another organism it will not. The latter phenomenon is due to the fact that 
it produces a marked increase in the polynuclears, which in some way are 
responsible for the non-reduction. The importance of cerebro-spinal fluid 
examinations in paediatrics needs no emphasis. 

Either constipation or diarrhoea may be present. The bladder acts 
well, although enuresis may exist. In some cases there is a marked retention 
of urine. The joints are usually swollen, simulating rheumatism. There 
is also a distinct petechial eruption in some cases. Out of a series of twenty- 
two cases seen by me, six had distinct petechia. In six others the skin had a 
distinct eruption resembling scarlet fever. Owing to the spots present in 
this condition, the disease was frequently termed "spotted fever." The 
pupils are usually dilated; they are sometimes irregular. I have seen cases 
during the epidemic of 1905 in which one pupil showed marked dilatation, 
while the other pupil was contracted to almost a pinpoint. Strabismus is a 
frequent symptom. Occasionally we note nystagmus. Photophobia is a 
frequent symptom. In one of my cases the child cried whenever a lighted 
candle was brought near the eyes. Opisthotonos is usually present. The 
severe rigidity of the sternocleidomastoid muscle in addition to the marked 
rigidity of the arms and legs forms a very prominent symptom during the 
course of the disease. Owing to these severe contractures we usually note 
constant moaning, most likely induced by the pain caused by the said 
contractures. 

Diagnosis. — A positive diagnosis of this disease can be made by examin- 
ing the fluid drawn by lumbar puncture. As a rule the spinal fluid is turbid 
or opaque. We do not find the spinal fluid clear and transparent, as it is 
seen in tuberculous meningitis. The presence of the characteristic diplo- 
coccus intracellularis described by Weichselbaum is usually noted. In rare 
cases the streptococcus and the pneumococcus have been found, but these 
latter are the exception. The bacteriological diagnosis, according to Weich- 
selbaum, depends on the diplococcus being Gram negative, or decolorized by 
Gram. It is important to remember that the Micrococcus catarrkalis is fre- 
quently found in the nasal passage; hence, great care must be exercised to 
differentiate the same, both in its relation to Gram staining and also in its 
morphological characters. 

The following two cases will serve to illustrate the method of 
treatment : — 

Case I. — Emilio G-., four months old, was admitted to the Sydenham Hospital, 
January 6, 1909. Family history negative. 

Personal History. — Normal delivery. Full term. Bottle-fed since birth. 

Present illness began two weeks ago with twitchings of the muscles. One 
week ago mother noticed retraction of the head. There had been no vomiting. The 
baby had moaned almost constantly. 

Physical Examination. — Head showed bald occiput. The anterior fontanel was 
open and slightly bulging. The pupils were equal and slightly contracted. There 



788 DISEASES OF THE NERVOUS SYSTEM. 

was marked retraction of the head, amounting to opisthotonos. The chest showed 
poor expansion. There was a systolic murmur heard at the apex of the heart. The 
lungs over left base, posteriorly, showed small areas of dullness, bronchial voice, 
and breathing. The abdomen was retracted. The liver and spleen were not 
palpable. There was marked rigidity of both arms and legs. The reflexes were 
exaggerated. Kernig's sign was not elicited. Lumbar puncture showed turbid fluid 
in which the Diplococcus intracellular is was found. 

The duration of the disease was thirty-six days. By means of ten lumbar 
punctures, I aspirated 146 cubic centimeters spinal fluid, and in nine intraspinal 
injections, I injected 245 cubic centimeters Flexner serum. The average injection 
was about 30 cubic centimeters. The child made a complete recovery without any 
sequels. 

Case II. — Intraventricular Method of Serum Injection. — Dora R., 1 two months 
old, was admitted to the Babies' Ward of the Sydenham Hospital, October 2, 1909; 
she was a well-nourished, breast-fed infant, having had no previous illness. There 
was a sudden onset with vomiting, loss of appetite, rigidity of head, neck, and extremi- 
ties, rolling of the eyeballs, insomnia, and convulsive movements. The anterior fon- 
tanel was open one-half inch in diameter, and slightly bulging. The posterior fon- 
tanel was almost closed. The pupils were equal, and reacted sluggishly to accom- 
modation and light. 

The thorax, ears, and throat were excluded as a possible source of disease. 

On the fifth day after admission, and on two succeeding days, lumbar puncture 
was performed resulting in dry tap. With the three successive dry taps, the symp- 
toms of rigidity, opisthotonus, fever, and twitching increased. 

On October 20th, I decided to tap the lateral ventricles by entering the ante- 
rior fontanel at the right angle. 2 The aspiration needle, about 8 centimeters in 
length, was introduced downward and toward the median line, at an angle of about 
20 degrees, to a depth of about 4.5 centimeters, the needle entering the lateral 
ventricles near the median line. About 15 cubic centimeters of turbid purulent fluid 
were withdrawn, which was identified at the Rockefeller Institute as a meningo- 
coccus intracellularis. The ventricles were then irrigated with normal saline solu- 
tion, at body temperature. The excess fluid was allowed to drain out through the 
needle, and 25 cubic centimeters of Flexner anti-meningitis serum were slowly 
injected into the ventricles. During the injection of the serum the infant changed 
in color from a waxy pallor to a uniform red flush all over the body. One-half hour 
after the injection of the serum the infant still remained flushed, perspired profusely, 
and had some frothing at the mouth. Otherwise the general condition was good. 
The temperature was 98° F.; respiration, 80, and pulse, 120. 

On October 21st, the ventricles were again irrigated with 40 cubic centimeters 
of normal saline solution, and 20 cubic centimeters of serum were injected. 

October 24th, the child's general condition was very poor. Opisthotonos was 
marked. The body rigidly bent in the form of a bow. The arms were rigidly 
extended and the palms everted outward. 

October 25th, and during the following week, daily injections of 30-50 cubic 
centimeters of serum were injected either into the ventricles or, on two days, into 
the spinal canal and lateral ventricles. The total amount of Flexner serum injected 
was 180 cubic centimeters ;' the total amount retained in the ventricles and spinal 
canal was about 100 cubic centimeters. The child made a complete recovery. 



1 This case was presented at the Section on Pediatrics, New York Academy 
of Medicine, March 10, 1910. 

2 See Plate XLI. 



PLATE XL 




Cerebrospinal Meningitis due to the Influenza Bacillus. A, A. Anterior 
cerebrum covered with a thick muco- purulent exudate. B, B. Normal 
cerebrum. C. Superior longitudinal sinus. D. Reflected integuments. 
E. Frontal sinus. This infection has been seen by me in an infant 4 months 
old. The infection probably enters through the lymph channels in the naso- 
pharynx, thus reaching the base of the brain. The bacillus may also have 
entered through the frontal sinus. In the spinal fluid as well as in the 
ventricular fluid a pure culture of the influenza bacillus was found. The 
infant died of convulsions. The autopsy performed by Dr. John Larkin 
showed the anterior two-thirds of the cerebrum was covered with a thick, 
muco-purulent, greenish exudate, cheesy in character. The convolutions 
of the cerebrum were obliterated and covered by a thick exudate, the 
surface of which was marked by many whitish nodules and a number of 
pits near the falx cerebri. At the frontal lobe of brain on right side 
a dark, necrotic area was seen. Illustration shows the calvarium removed, 
the dura mater incised longitudinally on either side of the superior lon- 
gitudinal sinuses and reflected laterally, exposing the entire cerebrum. 



CEREBROSPINAL MENINGITIS. 



789 



The symptoms are gradually subsiding, the rigidity is lessened, but on being 
handled opisthotonus is very evident. 

November 29th. No decided change, but infant improving slowly. The lateral 
ventricles were aspirated and 50 cubic centimeters of clear fluid which did not con- 
tain the meningococcus 
withdrawn. 

December 6th. In- 
fant was discharged 
cured. No complication 
of eyes and ears existed. 

It is now two months 
since this infant was dis- 
charged, she has since de- 
veloped a tooth, sleeps 
well, nurses well, and is 
a happy healthy infant. 

Lumbar Puncture. 1 
— The subarachnoid 
space is frequently tap- 
ped for diagnostic and 
therapeutic purposes. 
Either space between 
the third and fourth, 
or the fourth and fifth, 
lumbar vertebra? may 
be chosen. The child" 
is placed on either side 
with the spinal curve 
toward the operator, 
in this way spreading 
the vertebra? so that 
the greater angle formed by the vertebra? is toward the operator. An 
imaginary .line drawn through the crest of the ilium to the spine is an easy 
means of locating the place to puncture. 

Kind of Needle Required. — In making a lumbar puncture we should 
use such a needle as would be required in making a puncture for empyema. 




Fig. 263.'— Anatomical Illustration Showing the Place 
Best Adapted for Lumbar Puncture. The needle should 
be inserted in the lumbar space shown by the cross. 
(Original,) 



Fig. 264. — Lumbar Puncture Needle. 

The needle should be pushed a little upward and forward until it enters the 
spinal canal, then the stylet should be withdrawn. If the fluid does not 
escape through the needle, then withdraw it slightly and reintroduce the 
stylet to dislodge any obstruction in the caliber of the needle. Make the 



l First described by Quincke. 



790 



DISEASES OF THE NERVOUS SYSTEM. 



puncture as simple as possible rather than lacerate the tissue around the 
vertebral column and cause bleeding by lateral movements of the needle. 

Amount of Fluid to be Withdrawn. — For diagnostic purposes 15 to 20 
cubic centimeters should be withdrawn, if the fluid is watery and clear. If 
the spinal fluid is turbid, then the more we can withdraw, the better. I have 
withdrawn as much as 50 to 60 cubic centimeters. If the diplococcus intra- 
cellularis is found in the spinal fluid, it is especially important to with- 
draw as much of the fluid as possible. 

The site of puncture should be closed with a strip of adhesive plaster. 




J* 



Fig. 265. — Lumbar Puncture Made Between Fourth and Fifth 
Lumbar Vertebrae. 

Local Anaesthesia.— -Ethyl chloride in the form of a spray is useful in 
very sensitive children. It is not necessary to have general anaesthesia 
during this procedure. General rules of asepsis must be strictly applied to 
the child's skin, the operator's hands, and to the needle used. 

Dry Tap in Lumbar Puncture.— -We may have a dry tap : — 

1. If the caliber of the needle is small, and the spinal fluid very thick. 

2. If adhesions are present at the base of the brain, preventing the 
passage of fluid from the ventricles to the subarachnoid space. 

3. If a successful puncture has been made, a dry tap may follow, due 
to inflammatory adhesions caused by the previous introduction of the needle. 

4. The closing of the foramen of Magendie is the most frequent result 
of the inflammatory process, resulting in dry tap. 

5. A fibrin clot or the presence of the cord in front of the needle may 
prevent the outflow of the cerebro-spinal fluid. 



CEREBROSPINAL MENINGITIS. 79 1 

To be sure that we are in the spinal canal, if a dry tap exists, leave 
the needle in situ and introduce a second needle two spaces lower. Sterile 
water if injected through the upper needle will flow out of the lower needle, 
proving that we are in the spinal canal. 

The spinal cord in infants terminates about the level of the lumbar 
vertebrae. The introduction of the needle is simplest between the third and 
fourth, or the fourth and fifth, lumbar vertebras. In these interspaces there 
is no cord; hence no injury can follow. An imaginary line drawn through 
the crest of the ilium corresponds to the fourth intercostal space. 

Prognosis and Sequelae. — Heretofore the prognosis was always bad; 
since the introduction of the Mexner serum a decided improvement has been 
noted. Where formerly 70 to 80 cases died and only 20 to 30 cases 
recovered, we now have the reverse, 70 to 80 recoveries and only 20 to 30 
deaths. The prognosis is better if the serum treatment is given early in 
the disease. 

The duration of this disease may be short or very long. Young infants 
have been attended by me more than two months before recovery took place. 
Some cases after serum treatment recover entirely; others have atrophy of 
the optic nerve resulting in blindness. Deafness is a frequent and permanent 
injury in some cases. 

Treatment. — Fever Treatment. — Antipyretic measures such as cold 
packs, ice bag on the head, and tub baths are indicated. The coal-tar 
products, owing to their depressing effect upon the heart, should be avoided. 
Cupping of the neck and spine sometimes relieves internal congestion. 
Lumbar puncture should be performed. 

Eliminative Treatment.— -This consists in cleansing the gastro-intes- 
tinal tract with the aid of citrate of magnesia or calomel. When high fever 
exists, flushing the rectum and colon with a cold soap-suds enema will be 
found useful. 

Medicinal Treatment. — To relieve the vomiting cracked ice should be 
given, in addition to 1-grain doses of menthol. To relieve muscular spasm, 
twitching, and delirium, hyoscine hydrobromate, in doses of y^o to V300 
grain, should be given and repeated every few hours. Morphine hypo- 
dermically, in doses of 1 / 50 grain, gradually increased, is also valuable. 
Leeches applied at the nape of the neck, or over the mastoid portion of the 
temporal bone, or at the alae nasi will sometimes relieve. Sodium bromide, 
in 5- to 30- grain doses, may be given until the systemic effect is noted. 
Codeine, 1 / 10 grain gradually increased until % grain is given, will fre- 
quently soothe the nervous system. The soothing effect of a warm bath is 
generally recognized. The bath should be given at a temperature of 100° 
to 105° F. in a bathtub of water to which y± to V2 pound of sulphur has 
been added. A warm sulphur bath may be given twice a day. The dura- 
tion of each bath should be at least ten to thirty minutes. 



792 DISEASES OF THE NERVOUS SYSTEM. 

• Meningitis Serum. 1 — The specific value of the anti-meningitis serum 
has been demonstrated many times. In some cases reported there has been 
a sudden crisis and an amelioration of all the symptoms. My experience 
has been especially good in young infants under one year. While formerly 
all infants of tender age died, we now have a number of cases reported, 
including my own, in which absolute recovery has taken place. 

Intraspinal Injections. — By lumbar puncture we aspirate as much of 
the spinal fluid as possible; in some cases 15 to 30 cubic centimeters were 
obtained. Through the same needle left in siiu I inject from 30 to 60 cubic 
centimeters of Flexner's serum by the gravity method. The serum should 
be warmed before injecting, and should be injected slowly. It is better to 
elevate the hips and lower the head when injecting the serum. Daily injec- 
tions of 30 to 60 cubic centimeters are required if no improvement is noted. 

Intracranial Injections. 2 — The scalp should be shaved and prepared 
with the usual aseptic precautions. The aspirating needle must be rendered 
sterile by boiling. It is then pushed through the anterior fontanel down- 
ward and inward into the ventricles of the brain, at least one inch or more. 
The needle is inserted about one-fourth inch to one side of the longitudinal 
sinus. 

Kocher advocates puncturing through the frontal lobe at a point 2 1 /2 
centimeters from the middle line and 3 centimeters anterior to the central 
fissure — a point lying somewhat in front of the bregma. The needle must 
penetrate 4 or 5 centimeters before it reaches the ventricles and should be 
directed somewhat downward and backward. 

The ventricles at this situation are broad, extending fully 2 centimeters 
from the middle line, and there is practically no risk of haemorrhage during 
the passage of the needle. With experience and after practice on the cadaver, 
punctures may be safely made, not only at the point of Keen and Kocher, 
but elsewhere if need be — through the anterior pole of the frontal lobe, 
through the pole of the occipital lobe, etc. ; but these methods are more 
hazardous than those detailed above, and should only be undertaken by 
operators who are particularly familiar with intracranial work. In infected 
cases with a beginning external meningitis, there is always a certain risk of 
inoculating an uninfected ventricle. The same accident has occurred owing 
to the passage of an occluded needle through an abscess and then into the 
ventricle. A trochar should not be used. It is advisable to employ a needle 
with a sharply blunt point, which will pass by vessels without cutting them. 



1 1 am indebted to Dr. Simon Flexner, of the Rockefeller Institute, for the anti- 
meningitis serum used in these cases. 

2 1 am indebted to my house staff, Dr. Bobrow, Dr. Clurman, Dr. Littenberg, 
and Dr. Freund, for careful notes and records of a series of cerebrospinal meningitis 
cases treated at the hospital. See clinical case, page 788. 



PLATE XLI 




Translucent Head of Child. The needle entering the outer angle of the 
anterior fontanelle, and penetrating the lateral ventricle, which is seen in shaded 
outline. The falx is dimly seen. The right line running from before back- 
wards is the septum lucidum dividing the two ventricles. (Original.) 



CEREBROSPINAL MENINGITIS. 793 

The opening in the needle should be on the side and not upon the point; 
else they become plugged by the brain matter. 

At the Babies' Wards of the Sydenham Hospital we have aspirated, 
many times, 50 cubic centimeters of purulent liquid containing the diplo- 
coccus intracellularis in almost a pure culture. By using this same needle, 
or one having a larger caliber, we irrigated, using a pint of normal saline 
solution. After draining off as much as possible, 50 cubic centimeters of 
Flexner's serum were injected. This plan of treatment was successfully 
used in two of my cases. In both cases the lumbar puncture yielded a 
dry tap. 

The purulent discharge gradually lessened and the meningococci grad- 
ually disappeared after continued serum injections extending over a period 
of four weeks. It was possible to aspirate and draw off between 50 and 60 
cubic centimeters of a clear, transparent hydrocephalic fluid containing no 
germs. 

A decided reaction followed each and every injection of serum. During 
the injection of serum, the child changed in color from a waxy pallor to a 
uniform red" flush all over the body. One-half hour after the injection of 
the serum, the child still remained flushed and perspired profusely, and had 
some frothy mucus at the mouth. 

The pulse-rate was increased, the volume improved, and the tension 
much higher. The leucocytes were invariably increased. The polynuclear 
leucocytes were also increased after each injection. As a rule the mono- 
nuclear leucocytes and the lymphocytes were reduced within six hours after 
the serum injection. 

In the treatment of the severe type of cerebro-spinal meningitis, we 
must persist even though convulsions recur. We must afford relief by drain- 
ing the ventricles of as much of the cerebro-spinal fluid as possible. This 
must be followed up by an intraspinal injection of sufficient antimeningitis 
serum, as previously mentioned in this article. One of my cases was saved, 
although the prognosis was absolutely fatal, by the persistence of the above- 
outlined treatment. 

In an infant having an open fantanel it is a simple plan to aspirate 
the lateral ventricle, and thus relieve the intracranial pressure. I have fre- 
quently found persistent convulsions that would cease soon after the ven- 
tricles were relieved of the intracranial fluid. 

No one should expect to cure a case unless life is sustained with suffi- 
cient nutrition. Food must be given by mouth if possible. If the jaws are 
rigid, due to spasm, we must resort to rectal feeding of peptonized milk or 
peptonized yolk of egg with an equal quantity of starch water. The method 
of rectal feeding consists in first cleansing the rectum and colon by an in- 
jection of a pint of soap water, and after the parts are thoroughly cleansed, 
injecting quickly through a long catheter into the colon two or three ounces 
of the peptonized food. 



794 



DISEASES OF THE NERVOUS SYSTEM. 



Feeding. — Unless the strength is supported by food our patient will 
die of exhaustion. Feeding by mouth with peptonized milk, broth, gruel, 
and eggs is indicated. If, however, there is vomiting and the stomach does 
not retain food, then rectal feeding should be resorted to at intervals of 
three or four hours. This method of feeding has already been described 
in the chapter on "Infant Feeding." 

After Treatment. — If the case progresses favorably, careful attention 
must be given to restorative treatment. Codliver-oil, Fowler's solution, 
iodide of sodium, and the hypophosphites must not be forgotten. Electricity 
must not' be forgotten combined with massage and sea-salt bathing. They 
are indicated during convalescence. Milk, cream, butter, eggs and cereals 
should form the bulk of restorative nutrition. A decided change of air from 
the city to the sea-shore or to the mountains will prove beneficial. 

Acute Pachymeningitis (Inflammation of the Dura Mater). 

This condition frequently follows middle-ear disease, although it may 
be the result of injury to the cranium. It is frequently associated with 
inflammation of the pia mater (leptomeningitis). It is very difficult to 
diagnose. It usually follows ear disease and the symptoms of meningitis are 
associated. The treatment is surgical. 

Chronic Pachymeningitis. 

Chronic paclrymeningitis can be divided into' two forms — hemorrhagic 
and non-haemorrhagic. There may be punctate haemorrhages or there may 
be very large hemorrhagic areas. Some authors state that this condition 
is very rare. It affects the inner layer of the dura mater. It is frequently 
called pseudo-membranous and hemorrhagic, or hematoma of the dura 
mater. 

In cases where life is prolonged for years, there may be partial or even 
complete absorption of the clot, followed by the formation of cysts, con- 
siderable inflammatory thickening of the pia with deposits of blood pigment, 
and finally atrophy and sclerosis of the cortex. The source of the haemor- 
rhage may be the rupture of a single large vessel, but more frequently the 
blood comes from many small vessels. 

Symptoms and Diagnosis. — It is very difficult to give positive symptoms 
by which this condition can be recognized during life. Coma, convulsions, 
stupor, and vomiting are the main symptoms. Unilateral haemorrhage causes 
rigidity affecting one arm and leg, but if the haemorrhage is diffused all 
the extremities are affected. The pupils may be dilated or contracted; 
sometimes one pupil is dilated and the other is contracted. The respira- 
tion and pulse are slow and irregular. There is usually fever, the tem- 
perature being as high as 105° or as low as 100° F. 



CEREBRAL PARALYSIS. 795 

Opisthotonos may be absent. The patellar reflex is usually exag- 
gerated. Convulsions appear and death ends the scene. 

The differential diagnosis, according to Holt, is as follows: "Without 
large haemorrhages, pachymeningitis interna cannot be diagnosticated; and 
it is impossible to differentiate the haemorrhagic cases from other varieties 
of meningeal haemorrhage. It is important to make a diagnosis between 
pachymeningitis with haemorrhage, and acute simple meningitis. In the 
former we have a sudden onset; stupor occurring early, usually on the 
first da} r , gradually diminishing in cases of recovery, or deepening into 
coma in fatal cases; localized or general paralysis, also occurring early; 
there is no fever in the beginning, and only moderate fever at the close. 
In acute meningitis we usually have a higher temperature, especially early 
in the disease; coma develops later, and rigidity of the extremities is less 
pronounced. In certain cases, however, where the haemorrhage occurs in 
the course of some other disease, a differential diagnosis may be impossible." 

The prognosis is usually fatal. If small haemorrhages take place, the 
paralysis may remain for years. 

Treatment. — The scalp should be shaved and an ice-bag applied. 
Leeches should be applied to the mastoid to relieve cerebral congestion. 
Large doses of bromide and ergot will sometimes do good. The emunc- 
tories must be carefully watched and aided if necessary. 

Ceeebkal Paralysis (Spastic Diplegia. Paraplegia. 
Hemiplegia). 

There are two forms of palsy usually seen. When the face, arm, or 
leg is palsied it is called monoplegia. When the two lower extremities are 
affected, paraplegia. When one side is affected, haemiplegia. When both 
sides are affected, diplegia. 

They occur in one of three periods: first, during intra-uterine life 
(prenatal) ; second, traumatism during labor; third, palsies after birth 
of the child. 

Etiology. — Injury to the mother frequently injures the cerebrum of 
the foetus. Toxic conditions, especially those associated with the infec- 
tious disease resulting in muscular degeneration, frequently cause palsy. 
Compression of the infantile brain and its circulation during a slow labor 
may produce thrombosis or meningeal haemorrhage. This condition is most 
liable to occur in a primipara. Whooping-cough has caused cerebral haem- 
orrhage and injury and compression to the cortex ending in paralysis. 

Syphilis may be a frequent cause of this condition. Epilepsy is found 
in over two-thirds of all cases as a sequela. 

Pathology. — Very interesting data are contributed by Peterson and 
Sachs, to whom I am indebted for the following classification: — 



796 



DISEASES OF THE NERVOUS SYSTEM. 
Table No. 78. 



Groups. 



Pathological Changes. 



I. Paralyses of intra-uterine onset, 



II. Paralyses occurring during 
labor. 



III. Paralyses acquired after birth. 



Large Cerebral Defects (true porencephaly). 

Hemorrhages of Intra-uterine origin (soft- 
ening?). 

Agenesis Corticalis. 

Meningeal Hemorrhage (very seldom intra- 
cerebral). 
Resulting conditions : meningo-encephalitis 
chronica ; sclerosis ; cysts ; atrophies (poren- 
cephalies ) . 

Meningeal Hemorrhage (very seldom intra- 
cerebral) ; Embolism; Thrombosis (in 
marantic conditions and occasionally from 
syphilitic endart eritis ) . 
Results of these vascular lesions ; cysts ; soften- 
ing ; atrophy ; ^clerosis (diffuse and lobar). 

Chronic Meningitis. 

Hydrocephalus (seldom the sole cause). 

Primary Encephalitis (Strumpell) (?). 



"A summary of the pathological lesions resulting from acute ap- 
oplexies consists of atrophies, sclerosis, and other changes due to haemor- 
rhage; also, embolism and thrombosis." 

"Fatty degeneration of the blood-vessels is the probable explanation 
of the escape of blood in a large number of cases." Heart lesions, pneu- 
monia, and other infectious diseases predispose to embolism. 

The secondary changes result in sclerosis or areas of softening. "The 
sclerosis is largely responsible for the imbecility and epilepsy; transverse 
fibers connecting intimately all parts of the hemispheres." 

Spencer studied 130 cases of still-born children. He found 53 cases 
due to haemorrhage from the pia and arachnoid. In 29 cases there was 
bilateral hemorrhage, 10 in the left side only; 10 in the right side; 7 
in the lateral ventricles; 6 at the base of the brain; 1 case of intra-cere- 
bral haemorrhage; 4 cases of thrombosis of the longitudinal sinus. 

The following case occurred in the practice of Dr. A. C. Cotton, of 
Chicago : — 

Edith N., age 10 years, oldest in family of four children. Others normal. 
Mother not in good health during gestation. Labor lasted twelve hours. No 
forceps. Child was always irritable, but had no convulsions until four months of 
age, when first tooth appeared. There were frequent recurrences of spasms, two to 
four daily. Has never walked, stood alone, nor been able to support her head. The 
circumference of the head was nineteen inches. 



CEREBRAL PARALYSIS. 



797 



Present Condition. — The skin is cool, with a tendency to cyanosis. The body 
is emaciated; there is a flaring of the ribs, and the spleen shows a distinct scoliosis. 

The mouth is open so that the saliva constantly dribbles. The jaws are de- 
formed and the face presents a starched appearance. There are contractures and 
spasticity in both upper and lower extremities. The reflexes are exaggerated. In- 
telligence nil. 

Symptoms and Diagnosis. — The following symptoms are common to all 
forms of palsy : Kigidity of the muscles, contraction of tendons, and exagger- 




Fig. 266. — Infantile Cerebral Paralysis. (Kindness of Dr. A. C. Cotton.) 



ation of all the deep reflexes. Convulsions and coma commonly precede the 
diseased state. Most cases of diplegia and paraplegia are congenital, while 
most cases of hsemiplegia are acquired after birth. 

Palsies usually follow a difficult labor. Strabismus and facial paralysis 
are frequently noticed. Aphasia may be present in children that had 
previously learned to talk. The reflexes on the affected side, knee and 
elbow, are usually exaggerated (Peterson, Taylor, and Wells). 

When athetosis is found, it is usually associated with imbecility and 
idiocy. 

In associated movements the exact imitation of the paralyzed hand 



798 DISEASES OF THE NERVOUS SYSTEM. 

and fingers of voluntary movements made by the normal hand and fingers 
takes place. Choreiform movements, called by Weir Mitchell post-paralytic 
chorea, are frequently mistaken for chorea. Peterson 1 describes two con- 
genital hemiplegias — a hitherto unnoted morbid movement to which he has 
given the name post-hamiplegic poly myoclonus. The movements are neither 
choreiform nor athetoid, but are constant clonic contractions of most of the 
muscles in the limbs affected, not occurring synchronously, and the rhythm 
being about that of paralysis agitans (five per second). All of these move- 
ments indicate interference with motor conduction due to lesions in some 
part of the voluntary and inhibitory tracts. 

The following schedule of symptoms by Jacobi is useful in showing the 
diagnostic features of the different palsies: — 

Upper Extremity. — Deltoid : Absence Of deformity, which is averted 
by weight of arm. Inability to raise arm. Sometimes subluxation. Fre- 
quent association with paralysis of biceps, brachialis anticus, and supinator 
longus. 

Lower Extremity. — Ilio-psoas: Eare except with total paralysis. As- 
sociated with paralysis sartorius. Loss of flexion of thigh. Limb extended 
(if glutei intact). 

Glutei. — Thigh adducted. Outward rotation lost. Lordosis on stand- 
ing. Frequent association with paralysis of extensors of back. 

Quadriceps Extensor. — Flexion and adduction of leg (if hamstrings 
intact). Loss of extension of leg. Frequent association with paralysis of 
tibialis anticus. 

Tibialis Anticus. — Often concealed if extensor communis intact. If 
both paralyzed, then fall of point of foot in equinus. Dragging point of 
foot on ground in walking. Big toe in dorsal flexion (if extensor pollicis 
intact). The tendons prominent. Hollow sole of foot (if peroneus longus 
intact) . 

Extensor Communis. — Nearly always associated with that of tibialis 
anticus. Toes in forced flexion. 

Peroneus Longus. — Sole of foot flattened. Point turned inward. In- 
ternal border elevated. 

Sural Muscles. — Heel .depressed. Foot in dorsal flexion (calcaneus). 
Sole hollowed if peroneus longus intact; flattened if paralyzed. Point 
turned outward (calcaneo-valgus). 

Extensors of Back. — Lordosis on standing. Projection backward of 
shoulders. Plumb-line falls behind sacrum (unilateral). Trunk curved to 
side. Trunk cannot be moved toward paralyzed side. 

Abdominal Muscles. — Lordosis without projecting backward of 
shoulders. , ■< , 



1 Starr. American Text -book Diseases of Children, p. 652. 



CEREBRAL PARALYSIS. , 799 

Rigidity and contractures are striking symptoms in almost all these 
palsies, and for this reason they often fall into the hands of the ortho- 
paedic surgeons, who are besought to remedy the rigidly-flexed elbows, 
wrists, knees, and the various deformities that interfere with locomotion. 
Adductor spasm in the thighs, causing cross-legged progression, is nearly 
constant in diplegia and paraplegia. Talipes equino-varus is the most fre- 
quent pedal deformity in hemiplegia. Barely talipes equinus and talipes 
equino-valgus are to be found in hemiplegia. While rigidity with con- 
tracture is the rule in all of these forms of infantile cerebral palsy, occa- 
sionally, but very seldom, cases will be met with in which the muscles are 
all completely flaccid. The chief tropliic disturbance encountered in these 
cases is retardation in growth of the paralyzed member. The paralyzed 
limbs do grow, but at a much slower rate than the sound extremities. 
Hence the disproportion is often very striking. The earlier the onset 
of the palsy, the greater is this disproportion. Another peculiarity noted 
is that the growth of the whole organism is to a certain extent inter- 
fered with, the injury to the brain seeming to stunt development and 
to prevent the patient attaining his normal stature. The patients are more 
or less undersized and dwarfed. Peterson describes a case in which the 
mother brought to him her two boys, twins, 6 years of age, for the exami- 
nation of the one affected. One was a tall, well-built lad; the hemiplegic 
boy was small-bodied and fully seven inches shorter than his healthy 
brother. In all of these cases the muscles of the paralyzed and undevel- 
oped extremities react normally to the faradic current. There is no re- 
action of degeneration. In many cases the affected- limbs may be blue and 
cold, as in paralysis of the spinal type. A very rare phenomenon in these 
cases is a hypertrophy of the muscles, usually combined with athetosis. 

Asymmetry of face and skull have been observed. Peterson and E. D. 
Fisher have called attention to the flattening of the skull on the side op- 
posite the paralysis in infantile spastic hemiplegia. 

Differential Diagnosis. — From infantile spinal paralysis we can dif- 
ferentiate, by the presence of the exaggerated reflexes, the rigidity and 
normal reaction of the muscles. In cerebral palsy there is no actual atrophy 
in the limbs. When the central neuron is involved, the inhibitory influence 
over reflex manifestation is lost; consequently there is an increased reflex. 
When the peripheral neuron is involved, the circuit being broken, the reflex 
is lost. There are no marked trophic changes. 

Prognosis and Course. — -In diplegia and paraplegia- due to intra-uterine 
or birth 1 lesions they rarely reach the third year. As a rule they die of 
marasmus in infancy. In hemiplegia the prognosis is better. In most 
cases the paralysis may improve and the brain may not be seriously im- 



1 See article on "Erb's Paralysis or Birth Palsy in the New-born Baby." 



gQO DISEASES OF THE NERVOUS SYSTEM. 

paired. If epilepsy appears in later life, we may suspect a previous infan- 
tile paralysis. 

The palsy affecting the face and the leg can usually be improved. 
Speech will also gradually return if improvement is noted. The late ap- 
pearance of epilepsy must not be forgotten. Sometimes the paralysis is 
present a year or more before the onset of the epilepsy (Peterson). 

Treatment. — If convulsions are present, the inhalation of chloroform 
or laughing gas is indicated. Anti-spasmodics, such as bromide of potas- 
sium or bromide of sodium, with or without chloral hydrate, can be given. 
General attention to the stomach and bowels — and dietetic management 
is certainly indicated. Iodide of sodium is also indicated. Counter-irritants 
cause excitement and sometimes do harm. J. Madison Taylor advises 
against the use of counter-irritants. Electricity combined with massage 
is useful. The f aradic interrupted current will do good by stimulating the 
muscles. The current should be used daily; besides careful massage 
(muscle kneading), passive movements are of great importance. This form 
of exercise should be resorted to and more good can oe done by this form of 
treatment than by all medication. We must not expect the bodily 
functions to return to normal until we have strengthened the body with 
restorative treatment, combined with fresh air, and by all means light 
nutritious food. 

Some cases will not yield to medicinal treatment, and here surgical 
procedure has been advised. Neither trephining nor craniectomy have been 
successful. Allen Starr reports in a recent paper that in fifty cases oper- 
ated, in these and allied conditions, the results were not encouraging. 

A child 3 years old was brought to my clinic at the New York Post-graduate 
Medical School and Hospital in 1894. It was suffering with backward development 
and had distinct evidences of cerebral palsy. There was a diplegic paralysis. The 
head was microcephalic. As nothing could be done by general routine treatment, it 
was decided to try surgical treatment. A craniectomy was performed by Dr. 
Seneca D. Powell. The child died. 

Two other cases known to me have been operated, and the surgical 
treatment in each has been disappointing. 

Pleuroplegia (Mobius'sche Kernschwund) . 

This is a congenital condition caused by a combination of abducens, 
facial, and hypoglossal paralysis. 

This condition is caused by nuclear defects, and the partial palsies 
are evidently due to lack of intra-uterine development. The following 
case illustrates this condition : — 

C. M. G., born May 4, 1898, was referred to me for diagnosis by Dr. Henry A. 
Bernstein. 

Family History.— It is the first child. The mother has had two miscarriages 



PLEUROPLEGIA. 



801 



since the birth of this child. The parents are not related by birth. Syphilis can 
be positively excluded. 

Child's History. — She was breast-fed for three months; later received bottle 
feeding. When five months old it was noticed that the infant could not support its 
head. Dentition began at seven and one-half months. Did not walk until the third 
year. Had measles and also diarrhoea about this time and ceased walking, but began 
to walk again during the fifth year. Talking began when 5 years old. Could not 
connect words until 6 years old. Is inclined to constipation. Adenoids were re- 
moved when 3 years old. 

St. pr. — Now 7 years old. The heart sounds are clear and normal, although 
heart action is slow (bradycardia). The head moves normally. There is a funnel- 
shaped depression of the thorax, also a spinal curvature, pendulous belly, carious 
teeth, besides other symptoms of rickets. The nasolabial folds are totally absent. 
There is an absence of expression — no difference in laughing or crying. The saliva 
flows out of the mouth. The eyes do not close during sleep ( lagophthalmus ) . The 
iris disappears under the lids in attempting to close them. There is an absence of 
the secretion of tears. No fibrillary contractions of the tongue are visible. The 
uvula is in the median line just as in the normal child. 

Treatment. — Restorative treatment consisting of proteid food and general 
hygienic treatment to improve the rachitis was ordered. 

Codliver-oil and phosphorus may be tried, as also large doses of iodide 

of sodium. Faradic electricity is indicated. 

Pseudohypertrophic Paralysis (Muscular Pseudohypertrophy). 

We are indebted to Duchenne for an accurate clinical description of 
this condition. 

Etiology. — This disease is usually found in children between the sec- 
ond and eighth years. It is more frequently 
observed in males than in females. There is 
no distinct cause of this disease. 

Pathology. — The pathological lesions 
noted are a fatty infiltration of the muscles, 
changes in the breadth and contour of the 
muscular fibers, and an increase in the inter- 
muscular connective tissue. 

Symptoms. — Motor-weakness is usually 
the first thing noticed. A child apparently in 
good health will complain of inability to walk. 
At the same time there will be an enlarge- 
ment of certain groups of muscles. In cases 
seen by me the muscles of the calves were 
almost as large as those of the thighs. Stew- 
art has reported cases in which the calves of 
the child were as large as those of an adult. 
The muscles most frequently affected are the 
deltoids, biceps, triceps, latissimus dorsi, and 
sterno-mastoids. 

51 




Fig 



267. — Pseudohypertrophic 
Paralysis. 



I am indebted to Dr. Dexter Ashley for the 
above illustration. 



802 DISEASES OF THE NERVOUS SYSTEM. 

Duchenne has found all of the muscles of the body hypertrophied. 
After the hypertrophy disappears it is succeeded by an atrophic condition. 
There is less muscular irritability with faradic and galvanic currents. The 
patellar reflex is usually absent as the disease progresses. 

Case I. — A. L., 6 years old, boy. As a baby the mother noted that there was 
something the matter. Walked at 2 years of age. Child was very fat, and had a good 
appetite at that time. Now eats but little. 

Walks very erect, in soldier-like position, almost suggesting Pott's disease. . 
Steps slowly. On table, first noted apparently strong muscular development of the 
back. Muscles of back, thigh, calves, apparently well-developed.' Child rises from 
the floor with characteristic movements. Flat-footed. Cannot get up without roll- 
ing over, when reclining on back. Child looks to be in good health. Father says 
he is constantly growing weaker, slowly. Came to me for diagnosis, not having 
previously known the nature of the condition. 

Case II. — Jacob S., was first seen by me when 12 years old. Walking became 
impaired at the age of 6 years, gradually getting worse, so that to-day he cannot 
walk at all. The reflexes are absent. Sensation is impaired. The spinal muscles 
in dorsal region are atrophied. Gastrocnemii markedly increased in size. The 
extreme difficulty of rising from a sitting position is very characteristic. (Fig. 270.) 
The loss of power in arms is quite marked also. A history of diphtheria is given 
just prior to the onset. 

Dr. L. S. Manson kindly referred this case to me. 

Prognosis. — The prognosis as a rule is bad. 

Treatment. — The treatment consists in restoratives. Massage may be 
tried. Such a case should always be sent to a neurologist to outline the 
future course of treatment. 

Facial Paralysis in the New-born. 

This condition is most frequently seen in the new-born after the use 
of the forceps. It is a peripheral paralysis resulting from traumatism. It 

is the result of pressure on the nerve near the 
exit through the stylo-mastoid foramen or where 
the facial nerve crosses the ramus of the jaw. 
The parotid gland gives little protection in the 
new-born. The paralysis is most frequently 
unilateral, as usually only one blade of the 
forceps causes injury. 

Fig. 268.— Facial Par- FACIAL PARALYSIS (BELL'S PARALYSIS ). 

alysis following Mastoid 

Operation. (Original.) This is frequently called post-operative 

palsy. This disease may follow mastoid opera- 
tion. It may also follow retropharyngeal abscess (Bokai). 

The disease is sometimes associated with tumor in the cerebellum. 
Prognosis and Course. — Great care should be exercised in expressing 




PSEUDOHYPERTROPHIC PARALYSIS. 



803 




Fig. 269 



Pseudohypertrophic 
Paralysis. 

Fig. 269.— Note hyper- 
trophic condition of the 
muscles of the legs. Can- 
not stand without strong 
support. (Original.) 

Fig. 270.— Attempting 
to rise from chair. Com- 
pare atrophy of muscles 
of arms and spine with 
hypertrophy of muscles 
of legs. (Original.) 

Fig. 271. — Attempting 
to rise from floor. Can 
raise the body no higher. 
(Original.) 




Fig. 271. 



804 DISEASES OF THE NERVOUS SYSTEM. 

an opinion as to the outcome of a case of facial palsy. In one case seen 
by me after a mastoid operation a permanent palsy remained. I saw the 
case four years after the operation. 

Treatment. — This depends on the cause. Eestorative treatment aided 
by massage and electricity should be tried. Unless some improvement is 
noted within a few weeks the outcome of the case will be serious. 



Abscess of the Brain (Cerebral Abscess). 

This condition is occasionally seen in children. 

Etiology. — There are two principal causes of this condition: first, 
traumatism — injury to the head by a blow or a fall, resulting in fracture 
of the skull or in abscess; second, from an extension of middle-ear abscess 
into the mastoid cells, so that an abscess of the cerebellum results. The 
infection is carried through the veins or usually along the lateral sinuses 
to the cerebellum. Wagner reported a case of cerebral abscess in which 
thrush was believed to be the cause. 

The white substance of the brain is usually affected in this suppura- 
tive process. It is rarely seen in children under 1 year of age, but more 
frequently between the ages of 1 and 10 years. Out of 223 cases reported 
by Gower, 24 occurred between the ages of 1 and 9 years. Korner's statis- 
tics show that out of 77 cases of brain abscess, 25 were secondary to ear 
disease. 

In 38 out of 40 cases, according to Korner, the bone itself is 
diseased. 

Pathology. — Meyer reports a case of abscess which occupied an entire 
hemisphere. The pus found is usually greenish-yellow. At times the 
abscess may be encysted, in which case it is surrounded by a pyogenic mem- 
brane. Lalemand reports a case of abscess of the brain in which there was 
an escape of pus through the auditory meatus. "The most frequent seat of 
the abscess is, first, the temporo-sphenoidal lobe ; secondly, the cerebellum ; 
thirdly, the frontal lobes. Other locations are very rare. Abscesses are 
usually single. In size they vary from that of a cherry to an orange." 

"Abscess of the brain, as well as meningitis and sinus-thrombosis sec- 
ondary to otitis, begin, as a rule, at a point corresponding to that at which 
the inner surface of the bone is attached. The roof of the tympanum 
enters into the middle fossa, and the bony partition is sometimes as thin 
as writing-paper; it is for this reason that disease of the middle ear most 
often causes abscess in the temporo-sphenoidal lobe which lies on the fossa. 

The mastoid cells are separated from the posterior fossa by a thin 
layer of bone, and hence abscess, secondary to disease in that region, is 
often situated in the cerebellum. The extension of the disease to the brain 
is due to thrombosis extending from the diseased bone, or from the ear, 



ABSCESS OF THE BRAIN. 805 

through the veins which pierce the roof of the tympanum; only rarely is 
there a direct communication by a suppurating tract. In common with 
other forms of intracranial inflammation due to ear disease, abscesses occur 
more often on the right than on the left side." 

Symptoms. — If the child is old enough to complain, there will be 
headaches described over the affected area. Fever usually accompanies this 
condition. The temperature may rise to 104° or 105° F. in the beginning, 
although cases are reported where the temperature remains normal. Vom- 
iting usually accompanies this condition. At times in young children there 
are convulsions, coma, opisthotonos, and all symptoms pointing to a men- 
ingitis. When distinct areas are affected, such as the motor areas, then 
paralysis of the extremities may take place. Optic neuritis is sometimes 
present. A choked disc can sometimes be made out by an ophthalmoscopic 
examination. If the bones of the cranium are thin then there is usually 
marked tenderness over the region of the abscess. 

A foundling, eleven months old, was in a fair condition when first seen by the 
foster parents, who later adopted him. This infant subsequently developed sore eyes 
and still later had several bruises on the scalp which suppurated. In addition 
thereto he was emaciated and showed the evidence of both neglect and improper 
feeding. The infant with proper feeding and hygienic care developed into a bright 
healthy boy. He attended school and seemed in good health until his seventh year, 
when he showed signs of trouble with his head. Dr. W. B. Chapin, who attended him, 
suspected caries of the bones back of the ear. 

Dr. W. Freudenthal was called in consultation with Dr. Chapin to see the swelling 
behind the ear, which had developed during the previous eight weeks. The swelling 
was about the size of a large cherry, there was no pain on palpation and no spas- 
modic contractions. The swelling was located on the side of the head corresponding 
to the upper lobe of the ear. It was not reddened and fluctuated on palpation. Ex- 
amination of the ear showed no pathological condition. The drum membrane was 
normal. There was no tenderness over the mastoid.. 

After waiting some time it was thought advisable to open the abscess. The 
abscess was opened by Dr. Freudenthal with general anaesthesia. Necrotic tissue 
was found, but the mastoid was intact, and it was impossible to probe the mastoid 
cells; however it was found that a small probe penetrated in the direction of the 
frontal lobe to the depth of 3 1 / 4 inches. Pus oozed from this opening. As this was 
evidently a case of cerebral abscess, the wound was dressed and the further operative 
procedures left to a surgeon. The temperature ranged between 99° and 104V 2 ° E. 
The abscess was on the right side of the head. Convulsions occurred on the left 
side of the body. Dr. A. Gerster was called in and diagnosed the case as a cerebral 
abscess. On the following morning an operation was performed. To be sure that 
the mastoid was not involved, part of the mastoid was opened. It was found normal. 
Two ounces of pus were evacuated from the abscess. The case ended fatally. 

Diagnosis. — This :'s usually made when suppuration of the middle ear 
existed prior to this attack. If opisthotonos, symptoms of coma, convul- 
sions, high fever, or vomitng follow an attack of acute or sub-acute otitis, 



806 DISEASES OF THE NERVOUS SYSTEM. 

then an extension of the suppurative process should be suspected. At times 
the diagnosis will tax the ingenuity of the most expert aurist. 

Prognosis. — This is always grave. Our only chance for saving life is 
to resort to an early operation. 

Treatment. — The earlier surgical relief is instituted, the better will 
be the result. The medicinal treatment consists in relieving symptoms 
such as fever by means of an ice coil, and by active catharsis. Relieve the 
nervous symptoms with the aid of large doses of bromide and chloral. Com- 
plete details of brain surgery are given by M. Allan Starr in his book on 
"Brain Surgery." 

Alalia Idiopathica 1 (Backwardness in Speaking). 

When a child is in good health and does not learn how to speak, 
careful examination is necessary. In such cases it is important to exclude 
idiocy. Although some children do not speak before they are 2 or 3 years 
old, their general habits and mannerisms will easily show whether or no 
we are dealing with mental disease. 

The prognosis is excellent, although frequently parents will be very 
anxious and worried regarding- the outcome. 

Treatment. — Persistent teaching will usually remedy this condition. 

Idiocy and Imbecility. 

In idiocy we have a congenital absence of mentality and intelligence. 

In imbecility we have an arrested development or a partial arrest of 
development. 

Etiology. — According to Shuttleworth prolonged labor without in- 
strumental interference is the cause of idiocy in 29 per cent, of cases 
admitted to his asylum. Down states that of 2000 idiots examined by him 
there were symptoms of suspected inanition at birth in 20 per cent. This 
writer also states that disturbance of the mother's physical condition dur- 
ing pregnancy resulted in mentally deficient offspring in about 20 per 
cent. Griesinger states that "violent shock and grief during pregnancy 
appear not to be without influence as a cause of idiocy." Consanguinity is 
a much disputed point. Some authors believe that blood relations in- 
variably have mentally deficient offspring. Other equally observant writers 
hold the opposite view. I have seen a case of idiocy in which the father 
and mother were first cousins. Children of intemperate parents, and chil- 
dren of syphilitic and tubercular parents are frequently found to be men- 
tally deficient. 



1 Read also, "Very Late Speaking," Part I, page 3. 



IDIOCY AND IMBECILITY. 



807 



Shuttleworth, a well-recognized English authority in this field, gives the 
following classification of idiocy : — 



Table No. 79. 
class a congenital. 



- 




1. Microcephalic. 

2. Hydrocephalic (also non-congeni- 
tal). 

3. Scrofulous. "Mongol type." 

4. Sensorial (also non-congenital). 

5. Primarily neurotic. 

6. Paralytic (also non-congenital). 

7. Choreic (also non-congenital). 

8. Cretinoid: (a) sporadic, (6) en- 
demic. 

CLASS B — NON-CONGENITAL. 

(a) Developmental. 
9. Eclamptic. 

10. Epileptic. 

11. Syphilitic. 

12. Post-febrile (also accidental) . 
(b) Accidental or Acquired. 

13. Toxic. 

14. Traumatic. 

15. Emotional. 

16. From mixed causes. 

Symptoms and Diagnosis. — 
Great care must be taken in dif- 
ferentiating between backward- 
ness and idiocy. A child that is 
backward in development does 
not remain stationary in develop- 
ment, but progresses very slowly 
in comparison with children of 
the same age; for example, a 
backward child of 5 or 6 years 
will show the mental development of a child but 2 or 3 years old. In such 
a case we deal with a slow mental progress, whereas an idiot shows a distinct 
arrest of development, both of body and mind. 

Down describes Mongolian idiocy in the following language: "The 
hair is not black as in the real Mongol, but of a brownish color, straight 
and scanty; the face is fiat and broad, and destitute of prominence; the 
cheeks rounded and extended laterally; the eyes obliquely placed, and the 
internal canthi more than normally distant from one another (the epi- 
canthic fold often abnormally large) ; the palpebral fissure very narrow ; 



Fig. 272. —Congenital Idiocy (Lillie B.). Age 6 
years. Deli ate until 4 years of age. Did not walk 
until the fourth y< ar. Mother tannot tell when 
difference in the two sides was first noted. There 
were no convulsions. The head measured 19 inches. 
There were strabismus, and deformed jaws. The 
mouth was constantly open. Right hemiplegia, 
more marked i n upper extremity. Walks and runs 
around, but drags right foot. Contracture and 
spasticity presenr. Expression idiotic. Has never 
talked. Intelligence nil. Is restless and in ne.irly 
coi.stant motion. (Case of Dr. A. C. Cotton.) 



808 



DISEASES OF THE NERVOUS SYSTEM. 



the forehead wrinkled transversely, from the constant assistance which the 
levatores palpebrarum derive from the occipito-frontalis muscle in the 
opening of the eye; the lips large and thick, with transverse fissures; the 
tongue long, thick, and much roughened; the nose small; the skin has a 
slightly dirty, yellowish tinge, and is deficient in elasticity, giving the 
appearance of being too large for the body. 




Fig. 273.— Imbecile (Louie W.). Showing 
anterior curve of the spine and general 
atrophy of all the muscles, especially 
those of the back and shoulders. 
(Original.) 



Fig. 274.— Imbecile (Louie W.). Showing 
normal position of head flexed on the 
chest. Can only lift head by raising chin 
with extensor muscles of hand and fore- 
arm. (Original.) 



"This type occurs in more than 10 per cent, of cases; they are always 
congenital idiots; they have considerable power of imitation; they are 
humorous; they are usually able to speak, the co-ordinating faculty is 
abnormal; the circulation is feeble; the improvement which training 
effects is greatly in excess of what would be predicated if one did not 



IDIOCY AND IMBECILITY. 



809 



know the characteristics of this type; the life-expectancy is, however, far 
below the average, and the tendency is to tuberculosis/' 

These children are usually found to be deaf, blind, or to have some 
deformity of the mouth, nose, hands, or feet. I have seen cases of this 
kind in my service at the various hospitals of New York, and also re- 




Fig. 275.— Imbecile (Louie W.). 
Showing position assumed in walking. 
Cannot stand on feet. (Original.) 



Fig. 276.— Imbecile (Louie W.). 
Showing drop wrist and foot. (Original. ) 



member seeing this form of disease at the Children's Klinik of Dr. Hugo 
Neumann, at Berlin. This disease usually ends fatally. 

I allude to infantile amaurotic idiocy on page 810. Other forms 
of mental impairment are described in detail (see article on "Sporadic 
Cretinism," page 719). 



810 DISEASES OF THE NERVOUS SYSTEM. 

An Imbecile Having Microcephaly and Pseudo-muscular Atrophy. — Louie 
W., 5 years old, was referred to me through the courtesy of Dr. L. S. Manson. 

Previous History. — This child was born at full term, natural labor, no forceps. 
He was breast-fed about 15 months ; could not stand, walk nor talk until 2 years old. 
Dentition began during the ninth month, which was very early in this family, as all 
the other children teethed at fifteen months. He had measles when 2 years old, 
influenza and pneumonia when 3 years old. The boy has an unusually small skull, 
16 inches in circumference; the normal circumference at this age is about 21 inches. 

Family History. — The mother had been married twice, had six children with the 
first husband and five with the second. Three children died of scarlet fever. The 
rest of the children are strong and healthy. There is no family history of idiocy or 
nervous disease on either father's or mother's side. 

The mother first noticed trouble when the child was 2 years old, when he 
began to go about on his knees, having never walked on his feet. He has no power 
in the hands or feet; speaks very little, voice tremulous. Tic of small muscles of 
chin; knee-jerk both present. There is great muscular weakness of the lower ex- 
tremities and muscles of the back. There was drop-wrist and foot and universal 
wasting of the muscular system without marked trophic changes. Normal position of 
head is that of flexion on chest and can only lift head by raising chin with extensor 
muscles of hand and forearm. Fibrillary twitching of all the muscles in hands not 
amounting to athetosis. 

Infantile Amaukotic Family Idiocy. 

This peculiar condition has attracted considerable attention in recent 
years. In 1881 Tay, of England, described a case of symmetrical changes 
in the macula lutea. The child could not sit "erect and was backward men- 
tally, John Claiborne, reviewing this subject in 1900, refers to the above 
case, and says: — 

"At the first examination the optic disc was normal, but at the macula 
there was a white, more or less round area, in the center of which was a 
brown spot. The picture was similar to that seen in embolism of the 
central artery of the retina. Tay at first thought it was a congenital 
change. Five months later he noticed the optic disc was atrophied. Three 
months later he observed 3 other cases in the same family. In all the 
ophthalmoscopic picture was the same, and all these persons died before 
the end of the second } r ear of the disease. During the years 1885 and 
1886 the same ophthalmoscopic picture was described by Magnus, Knapp, 
and others. In 1887 Sachs reported a case which impressed him as being 
one of idiocy; this was particularly interesting on account of the changes 
observed in the cortical cells. The family character of the affection was 
suggested to him after observing 4 cases in two families. Kingden, of 
England, published a case and showed a picture which eye surgeons said 
belonged to the disease which Sachs had elucidated. In 1898 Sachs re- 
viewed the subject, tabulating 29 cases." 

A. Jacobi reported 3 cases of this form of idiocy to the American Ped- 
iatric Society in 1898. 



CONCUSSION OF THE BRAIN. 811 

Pathology. — Sachs states that the external configuration of the brain 
exhibits a distinct picture of a lower order of development. It is difficult 
to state whether the changes were to be regarded as primary degenerations 
or due to an arrest in development. 

Symptoms and Diagnosis. — There is "a milky-blue or white optic disc 
with bright cherry-red center occupying the place of the macula lutea." 
Nystagmus is frequently present. Hydrocephalus has been reported asso- 
ciated with this condition. The weakness of the extremities increases slowly 
until diplegia appears. In such cases the optic symptoms and idiocy are 
pronounced, and from these two conditions alone, the diagnosis can be 
made. The voluntary muscles are relaxed, especially those of the ab- 
domen. Death usually comes at the end of the second or third year, 
although the disease may last years. The child is totally blind. 

Treatment.— No treatment has as yet modified or benefited these 
children. 

Concussion of the Brain. 

We frequently see children who have fallen down a flight of stairs, or 
with apparently as severe symptoms, that will recover. The following case 
illustrates concussion of a mild type which recovered: — 

Case I. — A boy, 7 years old, rolled down a flight of stairs. I saw him about 
one hour after his fall. There was nausea and vomiting. Some slight abrasions of 
the skin were present, and a scalp wound one inch in length which required a stitch. 
The temperature was 100° F. The boy was put to bed. I saw him about twelve 
hours later. He was perfectly normal and complained of intense hunger. On the 
following day the boy was apparently well. 

Case II. — Severe Concussion of the Brain. — Child S. was seen by me through 
the courtesy of Dr. E. D. Lederman, with the following history: He was in his fourth 
year, bottle-fed during infancy, and excepting an occasional attack of dyspepsia, had 
always enjoyed good health. 

Present Condition. — Three days before I saw him he fell and struck his head 
violently on the pavement. Six hours later, severe vomiting set in. During the night 
following the fall he was feverish and moaned continually. On the following day 
when Dr. Lederman saw him the temperature was 103° F. The child seemed to be 
dazed and in a stupor at times. He was very thirsty. There were marked evidences 
of clonic and tonic spasms in the muscles of the body. A laxative was ordered. The 
gastro-intestinal tract was cleaned and an ice-bag applied to the head. These same 
symptoms continued, the fever rose to 105° F. and was not easily reduced. When I 
saw him in consultation with Dr. Lederman there were spastic conditions of the 
muscles of the arms and legs. There was marked rigidity of the spine. The sterno- 
cleido-mastoid muscles were rigid. There was marked opisthotonos. Severe photo- 
phobia. The pupils were dilated and did not respond to a strong light. The 
Babinski reflex was present on the right side, but not so positive on the left side. 
When moved about the child moaned as though in pain. A tache cerebrale was also 
present. The diagnosis of concussion and traumatic basilar meningitis was made. 
A lumbar puncture was made and almost one-half ounce of turbid (milky) cerebro- 
spinal fluid was withdrawn. The child passed urine involuntarily (evidently due to 
bladder paralysis). The case ended fatally. 



PART X. 

DISEASES OF THE EAR, EYE, SKIN, AND ABNORMAL 

GROWTHS. 



CHAPTEE I. 
DISEASES OF THE EAR. 

Acute Catarrhal Otitis Media. 

Acute catarrhal otitis media arises in the great majority of cases from 
extension of an inflammatory process by way of the Eustachian tube. 

Etiology. — Burkens found 104 deaths in 33,107 ear cases, and Eandall 
15 in 5000, giving a percentage of three-tenths of 1 per cent, from intra- 
cranial disease. 

Schwartz records 30 deaths in 8425 ear cases, or 0.35 per cent. The 
death rate from purulent ear diseases, compared with all other diseases 
treated, was shown in Guy's Hospital, in London, some years ago, to be 
57 deaths among 9000, two-thirds of 1 per cent; 40,073 autopsies in the 
Vienna General Hospital showed 232 deaths from otitic complications, i.e., 
0.58 per cent. The majority of these deaths occurred in the course of 
chronic suppuration of the middle ear, complications in the acute stage, 
with the exception of mastoiditis, being less frequent. 

Naso-pharyngeal disease, especially the infectious diseases, such as 
measles, scarlet fever, influenza, and diphtheria, are frequently fol- 
lowed by otitis. The ease with which pathogenic bacteria can cause an 
inflammatory extension from the nose into the Eustachian tube is now 
recognized. Children of the lymphatic and rachitic types are more sus- 
ceptible to these infections. 

When a catarrhal process limits its attack to the lower portion of the 
middle ear chamber, the disease may run its course without becoming 
purulent. When, however, the upper part or tympanic attic is involved, 
we are more apt to find that the infection assumes a suppurative type. It 
is in this class of cases that complications arise and extension to the mas- 
toid cells by way of the aclitus soon follows. 

Bacteriology. — Observers have found that even in the normal tym- 
panic cavity, pathogenic bacteria exist. Consequently any deviation from 
the normal process in this region predisposes the individual to a purulent 
infection. A passive congestion of the tympanic mucous membrane due to 
(812) 



PLATE XLII 




Normal Mucous Membrane of the Middle Ear in the Xew-born. 




Inflammation of the Mucous Membrane of the Middle Ear, 
Section of infiltration with polypoid excrescences. 



mUMM 







Section of the Vessel of the Mucous Membrane Containing Streptococcus 
Pj-ogenes. (After S. Weiss.) 



ACUTE CATARRHAL OTITIS MEDIA. 



813 



cardiac, renal, naso, or nasopharyngeal disease, must be considered a 
potent factor in the production of a suppurative otitis. Staphylococci, 
diplococci, and streptococci have been found in the naso-pharyngeal space, 
and it is reasonable to suppose that these micro-organisms are apt to find 
their way into the Eustachian tube and tympanitic cavity even under nor- 
mal conditions. 




Fig. 277. — Complication of Scarlet Fever seen in my service at Riverside Hospital. 

(Original.) 



A study of this case, in which both ears were discharging, is interesting. The 
temperature was only 99 2 / B ° F. in the rectum. This proves that we must always be 
on the lookout for suppuration of the middle ear in the acute infectious diseases. 

Pathology. — We must bear in mind that the ossicular chain is sur- 
rounded or enveloped by folds of mucous membrane, and when this tissue 
becomes engorged drainage from the attic is difficult. Consequently our 
incisions through the upper and posterior portion of the membrane in acute 
otitis should be deliberate and somewhat heroic, otherwise we will not 
accomplish the object in .view, i.e., drainage from that portion of the middle 
ear which is most likely to be followed by disease of the mastoid antrum 
and cells. 

Symptoms. — Two prominent symptoms are always present; one is 
pain and the other fever. The infant is usually very restless, rolling the 
head from side to side on the pillow and rubbing the hand over the affected 



814 DISEASES OF THE EAR. 

ear. At times the nose and throat will also be inflamed. Local tenderness 
can usually be made out on pressure. The examination of the middle ear 
with the speculum should always be made by one skilled in this work. 

Symptoms of meningitis are frequently present and will disappear 
when proper treatment for an otitis is instituted. I have frequently seen 
a case of persistent high fever, during the course of a scarlet fever, suddenly 
improve after the drum-membrane was incised. The temperature ranges 
between 100° and 105° F. A distinct rise of temperature does not always 
accompany this condition as is usual in other inflammatory conditions. 

Diagnosis. — This is easily made by one skilled in examining the ears. 
When a doubt exists the safer plan is to call in an aurist for an opinion. 
The neglect of this precaution may prove a serious matter, as deafness may 
follow. 

Prognosis. — The prognosis is reasonably good. 
We must not be too positive in giving a good prog- 
nosis, as sometimes fatal results follow the extension 
of the infLammator} r condition from the middle ear 
into the brain. 

Treatment. — Prompt drainage by an early inci- 
sion through the bulging membrane is the treatment 
indicated. To further drainage under such condi- 
tions it is wise to douche the ear with hot antiseptic 
solutions at a temperature of 108° to 120° F., using 
a return flow cannula. It has been claimed that the 
higher the temperature of the douche, the greater 

the possibility of absorbing the threatening mas- 
Fig. 278.— Ear Syringe. , ._. -f. J 8 & 

toiditis. 

Prophylactic Treatment. — As a soothing and prophylactic agent after 
incision or even before surgical intervention is indicated, a carbolized glyc- 
erine solution acts well in a number of these cases. In a very young 
child a 2 per cent, solution may be instilled into the ear after the same has 
been cleansed with a douche, every two hours. This may be increased in 
strength as the age of the patient progresses. Oily combinations should 
never be used as local agents in aural disease. They are apt to become 
rancid, and as the middle ear is an excellent incubator, affording bacteria, 
plenty of heat and moisture, infection rapidly occurs. 

General Treatment. — Peroxide of hydrogen or dioxygen is a valuable 
cleanser and deodorizer when the perforation of the membrane is large. 
The same remedy may cause extension of a purulent otitis if the aperture 
in the drum is small, and the liberation of its oxygen causes sufficient 
pressure to force the purulent foci backward through the aditus. Bulging 
of the upper portion of the membrane with a protrusion of the superior 
and posterior walls of the external auditory meatus, together with tender- 




MASTOID OPERATION ON INFANTS AND CHILDREN. 815 

ness over the mastoid antrum or tip, with some elevation of temperature, 
occurring during the course of an acute otitis, are indicative symptoms of 
mastoid involvement. Extensive disease of the mastoid cells may exist 
without the slightest rise in temperature, especially if the acute stage of 
the inflammatory process has passed by. 

We may safely assume that in all cases of catarrhal otitis the mucous 
membrane lining the mastoid antrum is involved simultaneously with that 
of the middle ear, as it is part of the same tissue. For this reason blood- 
letting, done under aseptic precautions, should be carried out as near the 
cavity as possible; therefore, an internal Wilde's incision carried through 
the posterior superior quadrant of the membrane is certainly a rational 
procedure. 

Eestorative treatment such as iron, codliver-oil, Fowler's solution, be- 
sides concentrated foods, must be remembered. Unless we assist the nu- 
trition of the body we cannot expect to cure the disease. If the symptoms 
increase in severity and the temperature persists, the dangers associated 
with mastoiditis must be remembered, and the skill of an otologist or a 
surgeon will be required. 

Mastoid Operation" on Infants and Children. 

In operating on infants and children it is important to remember cer- 
tain points wherein they differ from adults. These briefly mentioned are 
the following: — 

At oirth, in the mastoid the antrum exists as the only cavity, about 
the size of a small pea; the process is not formed until after the end of 
the first year, and the pneumatic spaces not until puberty. 

There are also frequently dehiscences filled with fibro-cartilage as the 
squamo-mastoid suture is not ossified at birth. So when making the pri- 
mary incision, the knife must be used gently until the periosteum is 
reached, and this likewise must be raised with the greatest care to prevent, 
in such cases, the instruments slipping into the cranial cavity. 

In curetting after opening the mastoid, it must be borne in mind that 
the bone tissue in childhood is soft, so that healthy tissue need not be 
sacrificed unnecessarily. 

The Operation. — During the operation, strict antisepsis must be ob- 
served. The space around the mastoid for two or three inches beyond 
should be shaved and made surgically clean. The auditory canal should 
be irrigated with a bichloride solution of 1 to 1000. Then under com- 
plete anaesthesia, with a scalpel, curvilinear incision should be made from 
end of the mastoid close to the insertion of the auricle to about one-half 
inch of its upper border, down to the periosteum. This is then separated. 

The bleeding is controlled either by clamping vessels, or with gauze 
wrung out of hot water. An Allport retractor or one of its modifications 



816 DISEASES OF THE EAR. 

should then be used, which not only answers the purpose of its name, but 
also stops the oozing. The parts should be separated with the auricle 
held forward so that the posterior and superior walls of the auditory canal 
and the whole field of operation is exposed to view. 

If the bone is bathed in pus this is wiped away and any perforation 
is examined with a probe. The opening is enlarged, either with a spoon 
or rongeur. Should no perforation or sinus exist, then the antrum should 
be opened either with a flat chisel or gouge and a mallet. The supra- 
meatal triangle is above the antrum. This is made by drawing one line 
horizontally with the superior border of the auditory canal, a second ver- 
tical one with the posterior, and a base line corresponding with the curvi- 
linear line between these points. 

The chisel should be used gently and tangential, and the bone chipped 
away in small sections, always working downward, forward, and inward. 
A probe should be used to determine from time to time whether the antrum 
has been entered, and also to examine the cavity made. 

As soon as an opening has been made, a rongeur should be used to 
enlarge it, and then thoroughly cleaned out with a Volkman's spoon. The 
space leading from the antrum to the roof of the tympanum, that is, the 
aditus and attic, should be carefully cleaned out with a small curette. The 
antrum should then be carefully extended backward until the lateral sinus 
is exposed and inspected as to whether its appearance is healthy. Its pres- 
ence can be determined by its bluish appearance and the soft feel to the 
probe. All granulations and soft tissue having been cleaned out, the parts 
are gently irrigated with a bichloride solution of 1 to 5000, normal salt 
solution, saturated solution of boric acid, or sterile water if considered 
necessary. The wound is then wiped dry, the upper and lower ends can be 
stitched together, and the rest packed somewhat lightly with iodoform 
gauze. Bury this gauze; that is, do not let it project; then over this 
draw the parts together and apply layers of sterile gauze, absorbent cotton, 
and a bandage. 

After-treatment. — Unless pain or a rise in temperature occurs, it is 
frequently not necessary to change the dressing for five or six days. Usually 
there is no discharge in the auditory canal ; if there is, it is gently irrigated 
or wiped out. For the mastoid wound, a dry wiping is all that is neces- 
sary usually, and a dressing of sterile gauze used lightly packed. This can 
be changed every two or three days. Granulation tissue of course must be 
cauterized. 

Accidents During the Operation. — Wounding the lateral sinus may 
cause a profuse haemorrhage. If the bony cortex has been sufficiently re- 
moved, the sinus may be plugged with iodoform gauze and the operation 
completed. The sinus whenever exposed should be kept covered with iodo- 
form gauze separate from the rest of the cavity to prevent infection. If 



MASTOID OPERATION ON INFANTS AND CHILDREN. 



817 



the vessel should not be sufficiently freed from the bony covering, the 
bleeding may prevent the completion of the operation. 

Exposure of the Dura. — If carefully dealt with, this is not a matter 
of much importance, if the part is kept covered with iodoform gauze inde- 
pendent of the rest of the wound. If the dura should be wounded it should 
be opened, cleaned, and sewed up with fine catgut sutures. 

Facial Paralysis. — In operating, this condition can be prevented by 
not interfering with the lower two-thirds of the posterior wall of the 



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Fig. 279. — A Common Type of Acute Mastoid Inflammation Following 
Influenza. Th^re was a double otitis before the extension to the mastoid 
cells. Note the fever curve following the operations. Case recovered. 
(Original.) 



auditory canal and the facial nerve will escape injury. Where it has been 
slightly injured, the function of the nerve is usually restored within four 
to six weeks, 

Francis M. C, 1 year old, suffered with gastric disturbance, poor appetite and 
symptoms resembling colic. His bowels moved sluggishly, the stool was greenish and 
contained mucus and undigested particles of casein. He emaciated owing to the 
non-assimilation of food. From the history I learned, that the child has had fever 
accompanied by catarrh of the nose and a general bronchitis for the last four weeks. 
The examination of the body showed a decidedly rachitic thorax and distended 
abdomen; retarded dentition and general backwardness in development. There was 
no evidence of pulmonary disease. The heart-sounds were feeble and a hsemic 
murmur was distinctly heard at the apex of the heart and also in the vessels of the 
neck. The child perspired very freely. The temperature was 102.4° F., pulse 140, 
respiration 28. The throat showed enlarged tonsils and also adenoid vegetations. 
This latter condition was reported by Dr. Charles D. Manson. Both ears were dis- 
charging. The child was very restless, moaned and fretted continually and did not 
sleep at night. My diagnosis was influenza, subacute gastric catarrh, rachitis, and 
mastoid involvement. Dr. Edward Dench saw this case at my request and corrobor- 

52 



818 DISEASES OF THE EAR. 

ated the diagnosis. The temperature rose to 103.6° F. The right mastoid was 
opened by Dr. Deneh at the New York Ear and Eye Infirmary. The temperature 
came down by lysis to normal. Three days later, while the child was doing quite well, 
the temperature again rose to 103.6° F. A left mastoid was suspected, and accord- 
ingly the second operation was performed. On the day following the operation the 
temperature rose to 104.2° F., and an acute milk infection was suspected. With the 
aid of mist, rhei et sodii and a diet of whey only, at intervals of three or four hours, 
the stomach symptoms subsided, and four days later the child was removed from the 
hospital to its home in a normal condition. With careful asepsis both wounds healed. 
The child gained in weight and within one month had entirely recovered. 

Sinus Thrombosis. 

Mastoiditis is occasionally followed by a secondary infection of the 
lateral sinus. 

Symptoms. — There is usually a sudden rise in the temperature, ranging 
from 100° to 105° or 106° F. The temperature rises rapidly and falls 
rapidly. Unusual variations will be noted in the temperature so that it 
will drop from 106° to 98° F. and again rise to its former height. Bactere- 
mia is usually present. The blood shows a marked leucocytosis and a high 
polynuclear percentage. In doubtful cases a blood culture should be taken. 

Treatment. — The treatment is surgical. In many cases resection of the 
jugular vein is necessary. The outcome of the case depends on the vitality 
of the child at the time of operation. 

Serum Treatment. — When we are dealing with a pneumococcus infec- 
tion, an injection of antipneumococcus serum, 30 to 50 cubic centimeters, 
may do good. If no benefit follows, repeat the injection in twenty-four 
hours. 

The serum is indicated if resistance is low with a correspondingly low 
leucocyte count in the early stages of the disease. 

Foreign Bodies in the Ear. 

Insects, bugs, cotton, beads, and pieces of pencils are frequently found 
in the meatus. When beans or peas remain they swell and cause painful 
pressure symptoms. The specialist should invariably be consulted rather 
than risk the danger of traumatism in unsuccessful attempts at removal. 
If a live insect or bug is in the middle ear, pour water, oil, or alcohol into 
the ear. If the insect is not dislodged by this means try Allen's foreign- 
body forceps. 



CHAPTEE II. 

DISEASES OF THE EYE. 1 

Acute Catarrhal Conjunctivitis. 

This condition is usually associated with infectious diseases. As a 
rule it is found in coryza, the acute exanthemata, influenza, and the usual 
infections due to pathogenic bacteria in the atmosphere. 

General Plan of Cleaning the Eye when Secretion Exists. — The eyes 
should be thoroughly cleansed with a pledget of cotton dipped in lukewarm 
water. Then use a drop or two of a solution of cocaine : — 

I£ Cocaine hydrochlorate 10 grains 

Salicylic acid Va grain 

Distilled water , 1 ounce 

M. Drop into the eye 3 times a day. 

After instilling the cocaine, a few drops of a 2 per cent, argyrol 
solution should be dropped on the eyelid. The irritating secretions 
should be wiped away as frequently as possible. A weak solution of bichlo- 
ride of mercury, 1 to 5000, applied on cotton, will best serve to cleanse the 
eye. It should be used at a temperature of 100° F., hourly if necessary. 

A solution of borax: — 

]$ Biborate of soda 4 parts 

Distilled water 100 parts 

Or:— 

R. Argyrol 1 part 

Distilled water 100 parts 

are very good cleansing remedies. 

Peroxide of hydrogen, 2 one-half strength, is recommended by Stephen- 
son, to be used three times a day. 

Atropia is simply mentioned to be condemned. Protargol and largin 
stain the conjunctiva and are useless. To prevent the lids from gluing 



1 The correction of Errors of Refraction, such as astigmatism by means of eye- 
glasses, and the treatment of strabismus, should only be undertaken by the specialist. 
The reader is referred to special works on Diseases of the Eye for particulars regard- 
ing these conditions. 

2 A good preparation on the market is called dioxygen. 

(819) 



820 DISEASES OF THE EYE. 

together the yellow oxide of mercury ointment should be applied two or 
three times a day : — 

I£ Yellow oxide of mercury (5 per cent.) 1 part 

Vaseline 10 parts 

Lanoline 10 parts 



Pink Eye. 

This form of acute ophthalmia is similar to the one just described. It 
is very communicable and most probably transmits infection by a specific 
organism. 

Weeks 1 was the first to describe a definite micro-organism causing 
this disease. The Weeks bacillus is short and has rounded ends. It 
stains very easily with methylene blue. It is intensely contagious and 
spreads rapidly, especially in schools. Children under fifteen years are 
especially susceptible. 

The diplo-bacillus of Morax was described by him in June, 1896, in 
the Annal de Flnstitut Pasteur. The inflammation is frequently due to 
the presence of the diplo-bacilli. The inflammation usually begins in one 
eye and infects the other a few days later. Its course may be either chronic 
or acute. 

Pneumococcus Ophthalmia. 

This disease is frequently seen in new-born children in which the 
lachrymal sac suffers. 

Grifford 2 described an epidemic in Omaha where several distinct out- 
breaks took place within a few years. 

Veasey 3 states that the pneumococcus is the most frequent cause of 
ophthalmia in Philadelphia. The bacteriological examinations of the or- 
ganisms are very easily made. A cover glass smeared with the pus, stains 
well with methylene blue. Under the microscope there are diplococci, 
cocci, and chains devoid of capsule. 

Infection of the conjunctiva sometimes occurs. This is frequently 
the result of impetigo contagiosa of the face or scalp. Infected secre- 
tions transmitted to the eye by the fingers usually set up this inflamma- 
tion. Little girls frequently transmit vaginal discharges on their fingers 
and thus cause infection. The common cocci of suppuration, namely, sta- 
phylococcus pyogenes aureus, albus, and citreus, are usually found in this 
discharge. 



1 Archives of Ophthalmology, 1886, No. 4, p. 441. 

2 Grifford: Archives of Ophthalmology, vol. xxv, 1896, p. 314. 

3 Veasey: Archives of Ophthalmology, vol. xxxviii, 1899, p. 301. 



MEMBRANOUS CONJUNCTIVITIS. 821 

Treatment, — Clean the eye by dipping small pledgets of absorbent cot- 
ton into lukewarm water, or dip the cotton into a 2 per cent, solution 
of borax. A medicine dropper can be filled three or four times with a 
solution of: — 

B Formalin l 1 to 2000 

Sig. : Wash or bathe the eye with this formalin solution every four hours. 

Very hot water applied on pledgets of sterilized cheese-cloth will re- 
duce the inflammation of the lids. In other cases, cold lead and opium 
wash will be very soothing and have a similar effect. We can prevent the 
lids from sticking together by applying vaseline at night. 

Purulent Ophthalmia (Ophthalmia Xeoxatorum). 

This is a purulent conjunctivitis of the new-born infant. It may be 
seen several hours, or sometimes appears several days, after birth. The 
amount of pus secreted is very large. When the lids are separated pus 
will be liberated. 

Etiology. — It is usually caused by an infection in the maternal pas- 
sages containing the gonococcus during labor. The pneumococcus has also 
been found in some cases. These pathogenic bacteria are carried directly 
into the eye, either by the secretions or by means of infected sponges or 
towels. Bacteriology has proven that all causes excepting distinct germ 
infection must be eradicated. 

Symptoms. — The lids appear red and swollen. The upper lid fre- 
quently overhangs the lower and the infant is unable to open the eyes. 
Stephenson states that 10 per cent, of children so affected remain totally 
blind. Of 446 cases of ophthalmia occurring in the practice of seven phy- 
sicians quoted by Stephenson, gonococci was found in 72.83 per cent. In 
Stephenson's own cases, out of 45 affected, 30 showed evidence of the gono- 
cocci, or G6.5 per cent. 

Preventive Treatment. — The Crede method is now universally used. 
As soon as the infant is born and the face wiped clean, the following solu- 
tion is dropped into the eye : — 

IJ Nitrate of silver solution 2 per cent. 

Sig. : It is best to let it fall from a medicine dropper on the eyeball. A slight 
inflammatory reaction is occasionally seen and if treated with a cold solution of 
formalin, 1 to 2000, disappears quickly. 

Membranous Conjunctivitis (Diphtheritic Conjunctivitis). 

We occasionally see membranous patches on the surface of the con- 
junctiva. This membranous deposit is sometimes distinctly diphtheritic, 



1 Formalin is a 45 per cent, solution of formaldehyde. Formaldehyde itself is a 
gas and a strong escharotic. 



822 - DISEASES OF THE EYE. 

a culture taken showing the presence of the Klebs-Loeffler bacillus. To 
differentiate clinically between the diphtheritic and non-diphtheritic type 
is sometimes impossible. I have seen membranous conjunctivitis at the 
Willard Parker Hospital in which the disease clinically resembled diph- 
theria and still the Klebs-Loeffler bacillus was absent. In one case seen 
by me the streptococcus alone was present. The clinical history of the case 
is an important guide in the diagnosis. If another case of diphtheria exists 
at the same time in the same house, the question of transmission should 
have weight in making the diagnosis. Every case of membranous conjunc- 
tivitis requires a careful inspection of the fauces. If croupous laryngitis is 
present, then a greater probability of diphtheria is warranted. 

Symptoms. — A grayish-yellow patch can be seen on the conjunctiva. 
The lids are very tender and swollen. They feel hard and thick on palpa- 
tion, and cannot be everted. Ulceration or sphacelation of the cornea 
usually follows. The same systemic disturbances may be noted as are found 
in diphtheria affecting the throat. There is usually fever, glandular en- 
largement, loss of appetite, general prostration, and cardiac disturbances, 
as has been described in the chapter on "Diphtheria." 

Prognosis. — A very guarded prognosis is necessary, as the outcome of 
the case depends upon the care bestowed and the time when the case was 
first seen. If the disease has been established a long time, a greater de- 
structive tendency must be presumed than if the case was seen when it first 
originated. 

Treatment. — First isolate. The communicable nature of this disease 
must be remembered. The family and friends should be warned of the 
danger. 

Local Treatment. — If the eyes are thick and swollen, an ice-bag or 
ice-cold pledgets of cotton soaked in bichloride, 1 to 2000, should be ap- 
plied. They should be renewed every five to ten minutes night and day, 
to produce a good result. In other cases warm, moist applications will 
alleviate pain and also reduce inflammation. 

Specific Treatment. — Diphtheria is diphtheria whether it is in the eye 
or in the throat, hence an injection of 5000 units of antitoxin should be 
given regardless of the age of the child. The same internal treatment 
which is described in the chapter on "Diphtheria" is recommended if we 
desire successful results in these cases. 

Granular Ophthalmia (Trachoma). 

The characteristic feature lies in the development on the palpebral 
conjunctiva of the so-called "sago grains." 

Granular lids must be carefully considered owing to their disastrous 
tendency. 



GRANULAR OPHTHALMIA. 



823 



The following table, slightly modified from Stephenson (' "Epidemic 
Ophthalmia/" 1895) gives the differential diagnosis between folliculosis 
of the conjunctiva and trachoma: — 

Table No. 80. 



FALSE OR FOLLICULAR GRANULATION. 

1. Oval or roundish transparent 
bodies the diameter of which never ex- 
ceeds from 1 millimeter to 1 1 / 2 milli- 
meters. Of a faint yellowish hue, ar- 
ranged in rows parallel to the lid border, 
and discrete. Most marked in inferior 
retrotarsal fold. 



TRACHOMA. 

1. Round, opaque, ill-defined bodies, of 
grayish-white color and extreme friabil- 
ity. Firmly and deeply embedded in the 
conjunctiva, their diameter not in- 
frequently reaches 2 millimeters or more. 
Tendency to become confluent and form 
masses or areas of trachomatous ma- 
terial. Most numerous and larger in 
upper retrotarsal fold. 



2. Little or no change in the structure 
of the conjunctiva. 



2. Structural changes always present. 



3. Papillary hypertrophy of upper lid 
slight. 



3. Marked hypertrophied papillae of 
upper lid generally present. 



4. Tarsus never implicated. 



4. Tarsus often involved. 



5. Disappear spontaneously generally 
and leave no scar. 



5. Spontaneous cure may occur, but 
only by cicatrization, which may be 
slight or extensive according to the 
amount of tissue involved. 



6. No ptosis. 



6. Ptosis nearly always present in 
some degree. 



7. No pannus. 



7. Keratitis in the form of pannus or 
ulcer in about 25 per cent, of the cases. 



8. No trichiasis, entropion, or cica- 8. Frequently leads to trichiasis, en- 

tricial contraction of the cul-de-sac. tropion, or shrinking of the cul-de-sac. 



9. Most frequent in persons under 20 
years. 



9. May occur at any age. 



10. Non-contagious. 



10. Conditionally contagious. 



This disease may frequently assume an epidemic nature. Dur- 
ing the last two years hundreds of cases have suddenly appeared in our 
city. The ease with which all infectious diseases spread in the congested 
portions of our city applies to trachoma. For this reason school-children 
and inmates of institutions and hospitals should have the eyes carefully 
inspected on admission to exclude trachoma. In our country the native 
American Indian suffers from this disease, so do the Irish, Polish, Italians, 



824 



DISEASES OF THE EYE. 



and the Teutonic races. It is therefore quite probable that this disease is 
spread more or less among all races. One race is exempt, namely, the 
negro. 

Treatment. — Of all methods, expression is the method generally used. 
The morbid tissue is thereby dislodged and removed. Actual cauterization, 
galvano-cautery, or the solid nitrate of silver stick is mentioned by some, 
but should be used only by those familiar with the eye. The advice that I 
give in my office to patients suif ering with trachoma, is to recommend them 
to an eye specialist. 




Fig. 280. — Trachoma, Showing Round, Opaque Bodies in Upper and 
Lower Lids. "Sago grain" type. From a photograph — frequent type seen 
in children. (Original.) 



Blepharitis. 

This disease is characterized by a sub-acute or chronic inflammation 
along the margin of the lids. 

Two classes of cases might be noted. First, those in which slight 
crusts appear on the edges which, when cleared off, show no loss of sub- 
stance; simply reddened margin. This would include the cases of mar- 
ginal eczema, so called. Second, those cases which, when cleared of crusts, 
show ulceration. 

The first class of cases seek treatment for cosmetic results. There is 
no pain, only a slight discomfort exists. These cases are all aggravated 
by exposure to dust, wind, heat, or long spells of work. 

The second class of cases is more serious. At first they present a dusky 
margin and gluing together of eyelashes, due to excessive secretion, which 



HORDEOLUM. 



825 



gradually progresses. Beneath the crusts ulcers form. Excoriations and 
pustules about the hair follicles interfere with the growth, so that the 
lashes fall out or become stunted. The vascularity continues, increasing the 
thickness of the lids with new connective tissue. The gradual contraction 
of this new scar tissue leads to e version of the lids with resulting epiphora, 
or overflow of tears, presenting a disagreeable, raw-looking surface. 

Treatment. — Generally speaking, the treatment consists of removing 
the crusts or scabs by any warm alkaline lotion, such as bicarbonate of soda, 
or biborate of soda, 10 to 20 grains; aquae, 1 ounce. Massage of the lids 
with red or yellow oxide or white precipitate, 2 to 8 grains ; vaseline, 1 ounce, 
should follow. 

A mild ointment should 
be used — a strong one in- 
creases the irritation. All re- 
fractive errors must be cor- 
rected. Epilation of the 
lashes sometimes promotes a 
cure when commenced in the 
early stages of the disease. 
The general condition of the 
patient must be looked after, 
and iron, arsenic, codliver- 
oil, or similar tonics and hy- 
gienic treatment as indicated 
should be prescribed. 

Hordeolum, or Stye. 

This disease is character- 
ized by an inflammation of 
the connective tissue about a 
hair follicle along the lid 
margin. A hard, circum- 
scribed, inflammatory nodule forms, which may suppurate. Occasionally, it 
remains as a hard lump, and still in other cases the lid becomes swollen and 
oedematous. A close examination, however, will show the inflammatory spot, 
which as soon as it appears yellowish should be incised and the pus evacu- 
ated. 

Treatment. — The general treatment consists in hot applications to 
favor resolution. To prevent successive crops, the massaging of the lids 
with an ointment of hydrarg. ox. flav., 1 / 2 to 2 grains ; vaseline, 2 drachms, 
has an excellent effect. The infection from the pus may be prevented by 
the use of argyrol in a 5 per cent, solution, one drop two or three times 
daily. 




Fig. 281.— Method of Everting Eyelid. 
(After Davis and Douglass.) 



826 DISEASES OP THE EYE. 

These successive styes show some disease of the lid margin, as blepha- 
ritis, some derangement of the general system, or eye-strain, especially in 
hypermetropia. 

Phlyctenular Conjunctivitis. 

This affection is one of childhood and is seen in malnutrition after 
the acute exanthemata; also in marasmic or scrofulous children. 

Small elevated spots, papules, or pustules the size of a mustard seed 
are found in this condition. When the epithelial covering is shed they 
become superficial ulcers. They are either single or multiple, and appear 
as pinkish, yellowish, or grayish spots. There is very often a great dread of 
light — photophobia — which leads to spasms of the lids — blepharospasm. 
There are also at times pain, burning sensation, and lachrymation. 

Treatment. — Local treatment consists of bathing with a saturated solu- 
tion of boric acid. If any excoriation exists at outer canthus, touching it 
with nitrate of silver generally effects a cure. 

If the symptoms show that the condition is subacute or chronic then 
stimulating applications are required, as: — 

3 Hydrarg. ox flav 4 to 8 grains 

Vaseline : . 1 ounce 

M. and apply three times a day. 

I have had excellent results by touching the affected parts lightly with 
a solid stick of alum or copper. 

If there is much corneal involvement: — 

IJ Atropin sulph V 2 grain 

Aq. dest 2 drachms 

Sig.: One drop in the eye once or twice daily may have to be used. 

For the blepharospasm, a force I opening of the lids, an occasional drop 
of a 2 per cent, solution of cocaine, or a sudden plunging of the head in 
cold water will relieve the condition. 

General Treatment. — This consists in the hygienic care of the child 
and tonic treatment. The eyes should be kept clean and open, dark glasses 
should be worn if necessary. No dark room, bandages, or eye shields should 
be allowed. The bowels should be regulated. The diet should be looked 
into. All sweets interdicted, meat given occasionally, and milk foods or- 
dered. Give plenty of fresh air, outdoor exercise, and bathing. Tonics, 
such as codliver-oil, syr. f erri iodide, strychnine, etc., should be given. 



CHAPTEK III. 
DISEASES OF THE SKIN. 

Eczema. 

This eruptive disease is very frequently seen in infants as well as in 
older children. 

Etiology. — Irritation, be it an irritant soap or an irritant discharge, 
can give rise to eczema. Eczema is frequently an external manifestation 
of toxic conditions. The frequency with which eczema is seen in children 
with dyspeptic conditions certainly invites consideration. Children having 
rickets are frequent sufferers with eczema. Some authors believe that 
pathogenic bacteria can enter the skin and set up eczema. While this ap- 
pears plausible, it remains to be proven. It is found associated with de- 
ficient elimination from the skin in the unclean, in dyspeptic conditions 
when the stomach and bowels are not properly functionating, and also 
when the kidne}'s do not properly act. I have frequently seen children 
with a facial eczema which appeared when oatmeal was given and disap- 
peared when the same was stopped. Eczema may be due to reflex irrita- 
tion. Holt says that cases which accompany dentition and those due to 
genital irritation can be called reflex. 

This disease can be either localized (regional), as when it is confined 
to the face or between the thighs, or it can be general or universal. 

Symptoms. — There is always an intense itching or burning with the 
appearance of the eczema. On the cheeks it usually begins with "small 
red papules, later these coalesce and there is a moist red surface exuding 
serum or sero-pus." Children scratch and thus usually produce bloody 
streaks. The crusts have a yellowish-brown appearance. There is a red- 
ness, thickening, and always scaliness of the skin. The glands in the im- 
mediate neighborhood are usually swollen; they rarely lead to suppuration. 

Eczema frequently spreads from the face to the forehead and the neck, 
and I have seen it involve the whole head. 

Imant G. S., seven months old, was nursed about six weeks at his mother's 
breast. He was then fed on top milk and barley water. As this disagreed he was 
given barley water. He then had dyspeptic, greenish stools, and the feeding was 
changed to milk and rice water, ivhich seemed to agree quite well. He gained steadily 
one-half pound every week for the next three months. He wae at the seashore all 
summer and had no evidence of summer complaint. When seven months old he 
was slightly constipated and with it had dyspeptic fermentation. His appetite was 
poor. It was necessary to stimulate the bowels to produce proper evacuations. 

(827) 



828 DISEASES OF THE SKIN. 

Teething appeared at about the eighth month. At the same time the child had a 
severe attack of influenza of the gastric type, with high fever, anorexia, and gastro- 
intestinal atony. At this time a scaly and papular eczema appeared on one cheek 
and rapidly spread to both cheeks. With the application of a bland ointment con- 
sisting of zinc oxide and vaseline it disappeared. One week later I again saw this 
child with a relapse of high fever and dyspeptic symptoms, and a severe eczema 
covering an area larger than before. It was very red and angry looking and weep- 
ing in character. A gauze mask saturated with calamine and zinc lotion (3 per cent.) 
produced a marked improvement, besides relieving the itching. Internally I gave rhu- 
barb and soda tablets in addition to cutting down the quantity of milk one-half 
of the previous strength. After three weeks of this form of treatment I was able to 
return to the former full milk feeding and the eczema did not return. 

CALAMINE LOTION. 

R Pulv. calamini 2 parts 

Pulv. zinci ox . 2 parts 

Glycerini 1 part 

Aq. calcis 30 parts 

Treatment. — Another cooling and antipyretic lotion that has served me 
very well is the following: — 

B Phenol . 20 drops 

Zinc oxid 3 drachms 

Calamine 2 drachms 

Glycerine 4 drachms 

Liq. plumbi subacet. dil 1 ounce 

Lime water q. s. ad 6 ounces 

The following are suggested: — 

I£ Zinc oxide 2 drachms 

Amyl -. 2 drachms 

Naphthalan 1 ounce 

Apply at night. (Dr. John Fordyce.) 

unna's soft zinc paste. 
R 01. lini, 
Aq. calcis, 
Zinci ox., 
Cretse of each, equal parts. 

Bland, unirritating applications, such as rice powder, zinc oxide, stearate 
of zinc, talcum, or cornstarch, are very cooling, and seem to act by absorbing 
the heat and moisture if any be present. 

Bathing in Eczema. — I have frequently found an apparently cured case 
of eczema break out anew with a red blush and eczematous patches after 
one ordinary cleansing bath was given. In the acute stages water should 
be omitted. Applications of a 5 or 10 per cent, calamine and zinc salve 
or lotion, as described in the clinical case above given, are very beneficial. 



ECZEMA. 829 

Soap should never be used. When hard crusts cover the surface of the 
skin and cannot be softened by the ordinary application of salves, the fol- 
lowing treatment should be instituted: A bland bath consisting of one 
pound of oatmeal in a cheese-cloth bag, thoroughly soaked in hot water for 
at least one-half hour, and enough water added to bathe the eczematous 
parts. After thorough soaking in this oatmeal bath the calamine and zinc 
or a 2 per cent, boric acid and vaseline ointment should be applied. One 
bath only should be given. The salve should be applied three times a day 
for at least one week. Irritating ointments, or those containing tar, should 
be avoided in the acute condition. 

Eczema Rubrum. 

The eczematous blush affecting the face may be mistaken for erysip- 
elas. Erysipelas usually occupies a smaller area, generally on the bridge of 
the nose. High fever usually accompanies erysipelas; this will easily dif- 
ferentiate the condition. The treatment is the same as that outlined in 
the article on "Eczema." 

SALICYLIC-SULPHUR PASTE. 

I£ Ac. salicyl 1 part 

Sulph. depur 5 parts 

Petrolati 25 parts 

Zinci oxid 10 parts 

Amyli 10 parts 

ICHTHYOL OINTMENT. 

Ifc Ammon. sulph. ichthyolat 5 parts 

Aq. dest 5 parts 

Adeps benzoat 15 parts 

Adeps lanae 25 parts 

Crusta Lacta. 

To soften the milk crusts which form on the scalp of infants, applica- 
tions of the following will loosen the crusts, after which they may gently 
be combed away: — 

fy Olive oil y 2 ounce 

Castor oil y 2 ounce 

Salicylic acid 4 per cent. 

Eczema Intertrigo. 

In fat children where two opposing surfaces of skin are in contact, 
such as between the thighs or toes or in the armpits, a red form of inflam- 
mation frequently ensues. It is sometimes accompanied by a thin, foul- 
smelling discharge, which may be serous, but very rarely is purulent. • This 
condition is more apt to be noticed in the unclean. 



830 DISEASES OF THE SKIN. 

Treatment. — Eemove the cause by separating the parts. Sprinkle 
freely with talcum, zinc oxide, lycopodium, fullers' earth, or any good 
infant's powder. In severe cases separate the parts by placing a sterile pad 
of cheese-cloth on both sides of which zinc salve is smeared. All warm 
clothing should be avoided. When severe excoriation results from dis- 
charges and is not checked by the application of bland salves, then cool 
lead and opium wash applied for a day or more is soothing and will reduce 
the inflammation. 

When infected conditions occur, apply:— 

IJ Hydrarg. ammoniate 10 grains 

Lassar's paste 1 ounce 

Erythema. 

Local irritation such as might be caused by a mustard plaster or the 
friction of a dress, producing a "chafe," or irritating secretions, such as 
a purulent ophthalmia or acrid discharge from the nose, produces this ery- 
thema. It is frequently seen in infants on the buttocks from lack of clean- 
liness. When seen on the buttocks it may be mistaken for syphilis. Ery- 
thema is easily differentiated from syphilis by the absence of snuffling of 
the nose, of the ham-colored eruption, and of the inelastic, cracked appear- 
ance of the soles and palms. 

Urticaria (Hives; Nettle Eash). 

This inflammatory condition of the skin appears very suddenly. No 
special portion of the body is exempt; thus, it may occur on the face, 
abdomen, or extremities. It consists of irregular-shaped blotches called 
wheals. When these spots disappear they leave no trace behind. There 
are several varieties of urticaria. 

Urticaria annularis occurs in rings. 

Urticaria figurata occurs in spirals. 

Urticaria vesiculosa has vesicles on the summit of the wheal. 

Urticaria bullosa is a bullous development on summit of wheal. 

Urticaria papulosa is a wheal combined with a papule. 

Urticaria tuberosa are giant wheals. 

Urticaria hamiorrhagica is a combination of urticaria with purpura. 

Urticaria pigmentosa is a pigmentation following the wheals. 

The form most frequently met with in children is likely due to (a) 
ptomaine. poisoning; (b) the result of some toxin in the system. 

Causes. — Shell-fish, strawberries, and frequently cereals seem to be the 
cause of urticaria in some children. There is usually some gastric or gastro- 
intestinal disturbance at the time of the appearance of this rash. There 
seems to be a peculiar idiosyncrasy in some children to quinine and to 



HERPES ZOSTER. 831 

other drugs which will bring out an attack of urticaria. A great many 
children have severe urticaria after an injection of antitoxin. (Eead 
article on "Antitoxin Bashes.") Insect bites will sometimes cause this 
condition. 

Symptoms. — There is severe itching, and scratching will frequently 
develop a new rash. Fever sometimes accompanies this condition. Urti- 
caria once seen is very easily recognized and is not hard to differentiate. 

The prognosis is usually good. We must remember that children prone 
to idiosyncrasies will have urticaria quite frequently; thus, it will depend 
on the diet as to whether or no the rash remains away. 

Treatment. — The first thing to do is to cleanse the gastro-intestinal 
tract with one or two teaspoonfuls of castor-oil, followed with 1 drachm of 
rhubarb and soda every three hours until the stools become loose, and the 
condition is improved. 

Locally. — The severe itching can best be allayed by making a paste 
of bicarbonate of soda and cold water. Bub this paste into the hives. A 
cool tub bath, containing several ounces of bicarbonate of soda, will fre- 
quently relieve the itching. Evaporating lotions, such" as lead and opium 
wash or a weak solution of vinegar and water, are soothing to some cases. 
In other cases the following will give relief: — 

R. Resorcin 1 part 

Menthol 1 part 

Phenol 1 part 

Alcohol 200 parts 

M. Apply with cotton. 

Large quantities of w T ater should be given for thirst. It will also aid 
in eliminating toxins through the kidneys. 



Herpes Zoster (Shingles). 

"This is an acute inflammation consisting of a group of vesicles. It is 
mostly seen over a surface of skin corresponding to a definite nerve tract. 
It is accompanied by neuralgic pain." 

Symptoms. — As a rule, there is a broad band of vesicles corresponding 
to the affected area, usually following a nerve tract along the limbs or along 
the borders of the ribs. It develops very rapidly and frequently resembles 
an erythema. The crop of vesicles is frequently so thick that they almost 
touch one another. 

Prognosis. — As this is a self-limited disease, the prognosis is good, 
although neuralgic pains may persist for some time after the disappearance 
of the eruption. 

Treatment. — Avoid irritant salves and use cooling dusting powders, 
such as bismuth, cornstarch, wheat flour, or powdered zinc oxide. The 



832 DISEASES OF THE SKIN. 

affected part should be covered with linen or gauze, not flannel or wool. To 
allay intense itching or inflammation use calamine and zinc lotion (see 
chapter on "Eczema"). 

Chloasma (Tinea Versicolor; Liver Spots). 

This is a very mild form of eruption in which brown patches of skin 
are seen. It is caused by the invasion of a fungus. 

Treatment. — The application of white precipitate ointment or 1 per 
cent, bichloride in alcohol has served me very well in removing the same. 

Psoriasis. 

This is a chronic inflammatory disease affecting the extensor sur- 
faces. It consists of a red, scaly patch in which white, silvery scales abound. 

Etiology. — There is no specific factor, as it is found in both the rich 
and poor, although it frequently follows malnutrition of the body such 
as we see after the acute infectious diseases. This condition also fre- 
quently affects children of gouty parentage. 

Symptoms. — The extensor surfaces are usually affected; hence the dis- 
ease will be found on the extensor sides of the arms and legs. The sym- 
metrical arrangement of this eruption on both sides of the body is a char- 
acteristic condition. 

Prognosis. — This should always be cautiously given. As the disease 
has a chronic tendency, it may remain for years unless actively treated. 

Treatment. — Locally : — 

IJ Chrysarobin 2 to 10 per cent. 

Petrolatum 1 ounce 

or as a varnish 

IJ Chrysarobin 2 to 10 per cent. 

Liquid gutta percha or traumaticine 1 ounce 

IJ Salicylic acid 4 drachms 

Chrysarobin 2 scruples 

Painted on daily, until reaction follows. 

Whenever treatment is given, it must be continued until every spot has 
disappeared; otherwise the condition will relapse. 

The primary infectious agent is the streptococcus; later we have the 
staphylococcus. 

Systemic Treatment. — No one must expect to cure this disease unless 
the emunctories are properly looked after. We must keep the bowels loose, 
and the kidneys active. The dairy products should be permitted ; also meat, 
vegetables, and fruit. 



PEDICULOSIS. 833 

Eestorative treatment such as codliver-oil, iron, and arsenic should be 
given liberally. In this disease arsenic proves itself of great value. Ar- 
senic need not be feared and can be given to children in very large doses. 
Fowler's solution, in 3- to 10- drop doses three times a day, is usually 
sufficient. 

Impetigo. 

This infectious and contagious disease is characterized by an eruption 
which may appear on any part of the body. It is most frequently seen on 
the exposed parts, usually on the face and hands. 

Symptoms. — There may or may not be fever at the onset of the erup- 
tion. The eruption usually commences on the face and hands. It is easily 
communicated. 

Treatment. — A tub-bath consisting of kali sulphur (one ounce), dis- 
solved in a porcelain or wooden tub full of water. The temperature of this 
bath should be about 100° F., and the duration of the bath about five 
minutes. This bath should be repeated every night," before retiring, for one 
week. If the sulphur bath cannot be used, then apply a 10 per cent, 
ammoniate mercury ointment rubbed up with zinc oxide. 

The following lotion may be applied several times a day : — 

Ifc Zinc sulphate 3.5 parts 

Copper sulphate 1 part 

Aqua 100 parts 

Pediculosis. 

Among the neglected or unclean we frequently see this condition. It is 
caused by the invasion of a parasite, the pediculus capitis. There is usually 
an eczematous condition and the adjacent glands are swollen. The habitat 
of the pediculus is in the hair, but it causes eczematous patches by irritation. 

Pediculosis is often complicated with impetigo. It spreads to the face 
and makes a picture of impetigo. The infection is primarily streptococcus, 
secondarily staphylococcus. 

Treatment. — First, remove the hair, if at all possible; if not, saturate 
the hair with petroleum, but avoid the scalp. This should be left on five 
or six hours, after which the scalp and hair should be saturated with equal 
parts of ether and tincture of delphin to loosen the nits, which can then be 
removed with a fine comb. The hair should then be thoroughly washed with 
soap and water. 

Miliaria Papulosa (Lichen Tropicus; Prickly Heat). 

This variety of skin disease is frequently seen in summer. It consists 
of bright-red papules on the summits of which there are very tiny vesicles ; 
at times pustules may also be seen. The eruption is usually confined to 

53 



834 DISEASES OF THE SKIN. 

those parts which are warmly clad, so that the abdomen, chest, and the 
extremities are most frequently covered. Eczema frequently follows this 
condition, and if severe scratching takes place, local infection ending in 
furunculosis may occur. The other parts of the body which do not have 
the eruption usually show extensive perspiration. This eruption comes 
and goes very quickly. It is frequently mistaken for scarlet fever. The 
absence of fever, the appearance of the tongue and throat, and the absence 
of the prodromal symptoms will easily differentiate this condition. 

Treatment. — Ehubarb and soda. or a dose of calomel at the beginning. 
If the kidneys are inactive, then 10 to 20 drops of sweet spirits of niter 
should be given, and repeated two or three times a day. For the intense 
itching the application of a paste consisting of bicarbonate of soda and 
water will stop the itching. The body should be made comfortable by 
removing all warm clothing. A tepid alkaline bath, temperature 70° F. — 
a bath to which several ounces of bicarbonate of soda have been added— 
is very grateful and will give quick relief. After the bath, dry the body 
thoroughly and dust cornstarch or wheat flour with talcum or zinc oxide, 
and let the child sleep with as little clothing on as possible. If im- 
provement does not follow within twenty-four hours, then the application 
of the following salve will relieve itching and reduce the inflammation : — 

I£ Zinc oxide -.. 1 drachm 

Calamine • 1 drachm 

Cold cream 1 ounce 

M. Apply three times a day. 

Miliaria Eubra (Strophulus Infantum; Bed G-um). 

This rash is the result of an irritation due to perspiration. It con- 
sists of red papules, sometimes having tiny vesicles. It is usually seen 
on the cheeks of .an infant and always upon the side on which the infant 
sleeps. 

The treatment is the same as that given in the article on "Miliaria 
Papulosa." 

SUDAMINA. 

Sudamina are small, pearly bodies occurring during fever or exhausting 
diseases. They are usually seen over the sweat ducts. They are easily 
absorbed and fresh crops take the place of these tiny vesicles. 

Lentigo (Freckles). 

This is a very common affection of the skin. It is usually seen in 
children over 5 years of age, and most especially in those having blonde 
or red hair. The skin is certainly more sensitive to sunlight in such cases, 
and successive crops of freckles frequently appear after exposure to the 
light. 



FURUNCLE. 835 

The treatment consists in protecting the skin against exposure to the 
light. The freckles can be removed by a mild form of counter-irritation, 
such as the application of a 1 per cent, solution of bichloride of mercury. 
Apply on cotton to the affected area for three or four successive hours. This 
form of counter-irritation destroys the skin, causing it to desquamate. The 
new epidermis which appears is free from this pigment. 

Seborrhcea. 

This is a very common condition of thick, dry, crusty formation which 
occurs on the head of infants. It most frequently involves that region 
surrounding the anterior fontanel. There are two varieties: (a) sebor- 
rhea oleosa; (b) seborrhcea sicca. Some authors state that if the vernix 
caseosa in the new-born is allowed to continue, it passes into a seborrhcea 
and may eventually become an eczema. When carefully examined, sebor- 
rhcea will be found to consist of epithelial cells, fat, and chiefly dirt. There 
are no inflammatory symptoms. When the scales are removed the skin is 
usually found normal: 

Treatment. — The following is recommended: — 

B Salicylic acid 15 grains 

Vaselin 1 ounce 

M. Rub the scalp thoroughly several times a day and leave on overnight. 
Wash scalp with soap and warm water the following morning. If necessary repeat 
several evenings and wash in the morning as above directed. Sulphur soap is useful 
in this condition. The officinal ointment of sulphur can be rubbed into the scalp if 
this condition recurs. 

Furuncle (Boil). 

This inflammatory condition occurs around a hair follicle or a gland 
of the skin. It is most likely caused by scratching, during which process 
there is an infection of the follicle with pyogenic bacteria such as staphy- 
lococcus pyogenes aureus. Frequently we see boils scattered through the 
scalp in large crops. At other times they occur singly. A boil begins 
as a small, red spot in the true skin, very tender, and growing larger and 
larger. On palpation the center is soft and there is a tendency to sup- 
puration. After suppuration has taken place, and the boil emptied, the 
swelling subsides. A furuncle has but one point of suppuration, whereas 
the carbuncle has many. A furuncle is usually a small swelling. A car- 
buncle very large, frequently several. inches in diameter. 

Treatment. — Aseptic surgical details are demanded in each and every 
instance. The scalp should be shaved. The area of the skin involving the 
furuncle should be washed with carbolated soap and water, and subse- 
quently with water. A free incision should be made, the pus liberated, and 
the part dressed with sterile gauze. When furuncles recur, then specific 



836 DISEASES OF THE SKIN. 

results can be obtained by an injection of an autogenous vaccine made from 
the patient's pus. The staphylococcus pyogenes vaccine can be injected in 
doses of 500 million daily. No more than five or six injections will be 
needed to effect a cure. I have also had good results with stock vaccine 1 in 
injections of 200 million, with an initial dose of 100 million. 

Iron, codliver-oil, and other restoratives are indicated. The value of 
nutritious food must not be overlooked. 

Chronic Pemphigus. 2 

This frequently follows the acute condition. It resembles the acute 
disease in producing a succession of crops of bullae. 

The prognosis depends on the condition of the child at the time when 
it was first, attacked. If the infant is underfed, and its vitality lowered 
thereby, then active restorative treatment should be instituted or the case 
will be lost. 

Treatment. — The blebs should not be ruptured. They should be al- 
lowed to dry. The surface of the skin in the immediate neighborhood 
should be protected by a bland, non- irritating ointment, such as zinc salve 
or diachylon salve. 

Sprinkling powder of zinc oxide, borated talcum, or cornstarch should 
be used. If the bullae rupture, the serum should be absorbed with a little 
cotton and the neighboring parts protected from the excoriating effect of 
the contents of the ruptured bullae. Careful attention must be given to 
the stomach and bowels. If necessary, a mild laxative should be given. 
The diet should be regulated both as to quantity and quality. 

ISLevus. 

There are two kinds of naevus usually seen: (a) pigmentary; (&) vas- 
cular. Pigmentary occur as small, rounded stains, which are either yel- 
lowish or dark brown. The cutis is raised, thickened, and frequently sur- 
rounded with a tuft of hair. They are most commonly seen on the face, 
neck, and hands. 

Vascular naivi may be level with the skin or appear as tumors which 
project beyond it. The former is due to an excessive development of the 
capillaries of the skin. Commonly met with, it is of a purplish hue, 
although it may be brick-red, claret-red, or a livid-blue color. They are 
most commonly seen on the face and neck. 

Treatment. — Blistering or caustics are recommended for the cure of 
this condition. I have frequently seen marked benefit from linear scari- 



1 Furunculosis vaccine or polyvalent staphylococcus vaccine. Parke, Davis 
& Company. 

2 See article on "Pemphigus Neonatorum." 



TINEA TONSURANS. 837 

fication by the Paquelin cautery. A radical operation should be considered 
if this milder form of treatment is unsuccessful. 

Tinea Tonsurans (Bingworm). 

This disease is caused by the trichophyton tonsurans. When located 
on the scalp it is called herpes tonsurans; when on other parts of the 
body it is known as herpes circinatus. 

Microscopical Appearance. — Squire says: "Under the microscope the 
stump of the hair appears ragged on either of its ends. Instead of break- 
ing with a clean fracture, like healthy hair, the broken ends are digitated. 
The structure, of the hair is greatly altered; its fibers are separated longi- 
tudinally, and the intervals filled with the spores of the trichophyton. On 
the surface of the hair are clusters of the same spores. The magnified 
piece of hair looks something like a bundle of faggots, with a number of 
berries sticking in clusters to its sides and ends, and stuffed here and there 
into its interstices. The spores of the trichophyton are rounded, have a 
well-defined outline,. and measure about Voooo i ncn across. In the earlier 
stages of the disease, when the hair has not yet become so brittle as to 
make it impossible to extract the root, it can be ascertained that the knob 
of the hair, as well as its root-sheath, is invaded by the spores of the tri- 
chophyton." 

The disease commences with more or less itching and redness of some 
parts of the scalp ; sometimes there is swelling. The hair growing on these 
patches loses its polish, and becomes dull. It is also brittle and easily breaks 
off near the root. This breaking off of the affected hairs gives the patch 
the appearance of having been lately shaved. There is a furfuraccous des- 
quamation plainly seen on the scalp. The hair follicles become erect and 
the patch assumes a goose-skin appearance. The margin of the patch is 
abruptly defined. There are usually several patches seen on different por- 
tions of the scalp. If we attempt to pull out the hair stumps by means of 
a tweezer, we will note that only a portion of it comes away, leaving the hair 
root in the skin. 

Treatment. — X-ray treatment was introduced by Sabouraud and Noire 
as a remedy that is promptly curative in ringworm of the scalp. Their 
method is based upon one measured application of this agent, sufficient to 
produce depilation, this latter ensuing two or three weeks after exposure, 
and without producing, at the most, more than the mildest x-ray er} 7 thema. 
Care must be exercised so that the slightest reaction is not exceeded ; other- 
wise there is risk of permanent baldness. It is not a method to be used 
by those inexperienced in the use of the x-ray. 

The essence of the method of Sabouraud and Noire (who use static 
machines for generating the current) consists in giving one exposure suffi- 
ciently long to produce depilation, yet not long enough to produce ill 



838 DISEASES OF THE SKIN. 

effects. This is done by employing some means of measuring the quantity 
of rays, and by keeping the vacuum of the tube at a point equal to about 
3-inch spark gap. Full directions of this treatment can be found in Stel- 
wagon's "Diseases of the Skin," 1910. 

The following method is also of value : — ■ 

Eemove the superficial scales with the tincture of green soap, or by 
the use, for a day or two, of the pure green soap spread upon a piece of 
lint. Corrosive sublimate in 1 per cent, solution may be applied once a 
day, or the tincture of iodine, or carbolic acid in glycerine, 1 to 16, or the 
white precipitate ointment may be employed. I prefer the chrysarobin 
collodion painted over the patch every day or every other day. Kaposi's 
naphthol ointment is recommended by Lassar. Tar or sulphur ointments 
or Lassar's paste may be employed in obstinate cases. 

Morris's thymol-chloroform oil is also beneficial. 

morris's thymol-chloroform oil. 

Ifc Thymol 1 part 

Chloroformi 4 parts 

01. olivae 12 parts 

Or:— 

SUBLIMATE SPIRIT. 

Ifc Hydrarg. chlor. corr 1 part 

Spts. vini rect 500 parts 

Or:— 

TANNIN-SULPHUR PASTE. 

Ifc Acidi tannici 5 parts 

Lac. sulph 10 parts 

Petrolati ; 50 parts 

Zinci oxidi 17.5 parts 

Amyli 17.5 parts 

Or:— 

. CHRYSAROBIN COLLODION. 

3 Chrysarobini . 1 part 

Collodii flexile 10 parts 

Verruca (Warts). 

These small tumors of the skin are frequently met with in children. 
They may resemble a bunch of carrots (verruca digitata) or they may 
resemble a cauliflower. In size they vary from one-sixteenth to one- 
eighth of an inch in height. They frequently are seen on the face, neck, and 
hands. They produce no discomfort and are not serious. 

Treatment. — Freeze the parts with ethyl chloride or ether. Pick the 
wart with a sharp curette. Another painless method consists in cauterizing 
first with pure carbolic acid, on top of which fuming nitric acid is applied. 



GANGRENE. 839 

In using the latter caustic method, the surrounding parts should be pro- 
tected with vaseline. 

Burns (Combustio). 

We frequently see burns of various degrees in children. 

They are usually caused by hot water, steam, acids, or alkalies. 

An intensely inflamed area surrounding a blistered surface is usually 
found. Pain and sometimes shock are noted. In some cases fever and a 
rapid increase in the pulse are noted. Violent reaction such as convulsions 
frequently occur in weak and rachitic children if a severe burn has taken 
place. 

This depends upon the amount of surface involved and on the condi- 
tion of the child at the time of the accident. Some children survive exten- 
sive burns with good care. As a rule a cautious prognosis should be given, 
owing to the risk of infection and danger of shock. 

Treatment. — Strict asepsis should govern the opening of all blisters. 
Cornstarch, wheat flour, europhen, or dermatol may be used locally. In 
addition thereto, linseed-oil and lime water, or calamine and zinc lotion 
(see chapter on "Eczema"), is very valuable. 

Air should be excluded by applying an ointment consisting of 10 per 
cent, ichthyol, 1 per cent, menthol, or % per cent, phenol with vaseline. 
In some cases Fordyce advises the use of 1 per cent, picric acid ointment 
over which narrow strips of oiled silk are placed to prevent the dressings 
from adhering. Cover with sterile gauze and bandage. 

Gangrene (Superficial Gangrene). 

This condition affecting the skin or extending to the deeper structures 
is characterized by a bluish-black discoloration resembling a deep form of 
cyanosis. 

Causes. — It is a destructive condition following the acute infectious 
diseases, especially scarlet fever or measles. Traumatism or pressure inter- 
fering with the circulation of the blood or robbing the extremity of its 
nutrition may result in a destructive gangrene. The following case of 
traumatic gangrene occurred in my practice; it was a traumatic gangrene 
due to interference with the circulation : — 

Baby A., ten months old, breast- and bottle- fed, was referred to me by Dr. A. 
Meyer. I found a temperature of 105° F., pulse 180, respiration 60. There was com- 
plete consolidation of one lobe of the left side. Bronchial breathing was plainly 
heard and there was dullness on percussion. 

The diagnosis of lobar pneumonia was made. With the aid of cold packs and 
small doses of strychnine, the child's condition improved. As I left the city, the case 
was treated by Dr. Khodoff, who gave me the following memoranda: — 

"The nurse administered a high rectal enema by suspending the child with a 
towel around the thighs. The circulation was thereby interfered with. I believe the 



840 



DISEASES OF THE SKIN. 



thrombosis, which appeared at about the saphenous opening, was of traumatic origin 
due to this interference of the circulation. The course of the gangrene was as 
follows: A bluish-purple spot about the size of a ten-cent piece appeared at the 
saphenous opening. The child previous to this showed indications of pain. It was 
fretful, tossing about, and very restless. The gangrenous area increased on the 
following day. It was decided to wait for a line of demarcation, as the child appeared 
to be in a state of collapse. On the third day after the first sign of gangrene 



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Fig. 282. — Case of Gangrene Following Lobar Pneumonia. Gangrene 
appeared on the tenth day of disease, due to a careless method of suspending 
the child by a towel around the thighs, which resulted in thrombosis, ending 
fatally. (Original.) 

appeared, a rapid spreading took place upward along Poupart's ligament and con- 
tinued above and involved the umbilicus." 

When I again saw this case the gangrene involved the whole abdomen. The 
temperature was 102° F., the pulse very feeble, and the child in a state of collapse. 
It was necessary to stimulate and feed per rectum. The child died in convulsions. 

Prognosis. — The prognosis is always bad, although surgery may be 
the means of amputating a gangrenous extremity and saving the rest of 
the body. 

Treatment. — There is no medicinal treatment worth trying. Surgical 
relief is our only hope. 



SCABIES. 841 

Symmetrical Gangrene (Kaynaud's Disease). 

This is an obscure condition in which the gangrene is symmetrical. 

Etiology. — It is caused, no doubt, by the invasion of pathogenic bac- 
teria. Infectious diseases which devitalize the body are believed to pre- 
dispose to this condition. Injury and haemorrhages, such as epistaxis, have 
been forerunners of this condition. 

Symptoms. — When acute there is fever and enlargement of the spleen, 
haematuria, or hemoglobinuria. The affected part feels cold and appears 
bluish ; sometimes there are vesicles containing a sero-purulent fluid. This 
condition lasts from two to three weeks, although it may extend over many 
months. The disease ends in mummification and gradual decay of the 
affected parts. The toes, fingers, ears, or tip of the nose may be the seat 
of this affection. 

Prognosis. — A cautious prognosis should always be given. While 
records of cures exist, the diagnosis may always be questioned. 

Treatment. — General restorative treatment, concentrated foods, and 
hygiene should form the basis of treatment. The skill of the surgeon may 
eradicate the gangrenous parts. 

Scabies. 

This is a contagious disease caused by the female acarus burrowing into 
the skin. The characteristic features of this disease are that it is found 
between the fingers, in the axillae, on the flexor surfaces of the wrists, and 
also around the genitals. The eruption is either a papule or a vesicle, some- 
times a pustle. There is an intense itching, and secondary infection 
results from scratching. Several children in the same family will usually 
be found so affected. 

The prognosis is always good. 

Treatment. — A hot bath, to thoroughly soak the body and soften the 
epithelial scales, should .be ordered. An inunction of 1 / 3 unguentum 
hydrarg., 2 / 3 vaseline should follow the bath. Sulphur soap may be used in 
addition to sulphur ointment if no benefit results from the foregoing 
treatment. 

Epicarin is unirritating and is of value in parasitic affections of the 
skin. Precip. sulphur sprinkled between the sheets at night affords relief. 

An excellent method advised by Ford} r ce is, first, a cleansing bath, fol- 
lowed by applications of the following: — 

Ifc Balsam Peru 1 drachm 

Sulphur y 2 drachm 

Betanaphthol 10 grains 

Petrolatum 1 ounce 

M. Sig. : Apply on affected areas. Repeat treatment three successive niglits. 

Strict supervision must be kept up for at least ten days. ■ 



CHAPTEE IV. 

MALIGNANT AND NON-MALIGNANT GROWTHS. 1 

Abnormal growths are frequently seen in children. Some of these 
are malignant, while some are benign. We must not suppose that children 
do not have malignant disease. I have seen malignant sarcoma involving 
the whole of the left lung which crowded the heart into the right axillary 
space. 

Spindle-cell Sarcoma of the Thorax. 2 

Gustav L., a male child of about 8 years, was first seen by me in July, 1900. 
His mother gave the following history: — 

He was breast-fed about ten weeks and owing to a diminution in the quantity 
and quality of her milk, she was forced to wean the child. He then received sterilized 
milk. This food was given until the child was weaned from the bottle at about the 
end of his second year. 

When about six months of age, a large, glandular swelling commenced behind 
the right ear, which necessitated an incision. The attending physician said it was 
an abscess. At this same time, he had a severe attack of gastric fever. This required 
careful dietetic treatment. Cow's milk was continued in a more modified form. 

At age of 1 year the child was attacked with measles, accompanied by a 
catarrhal bronchitis. Some cough remained and when the child' was 2 years old he 
had a severe attack of pertussis. When the child recovered, he remained well until 
he was 3 1 / 2 years old, then he was infected with scarlet fever lasting two months. 
Thus the child passed his infancy with some gastric derangement, followed by measles, 
pertussis, and scarlet fever. He did not have croup or diphtheria. 

"Family History. — This is good. The parents of this patient are both living, and 
apparently strong and healthy; they have two other boys, well and strong. There is 
no history of syphilis, rheumatism, gout, tuberculosis, epilepsy, nor anything of a 
malignant nature in the family, excepting this fact which is extremely noteworthy, 
that the grandfather had a sarcomatous tumor, which ended fatally. 

"Examination. — The patient was brought to me for the relief of a number of 
tumors on the front of the thorax, which felt quite hard on palpation. At times a 
distinct sense of fluctuation could be made out, and when examined by an exploratory 
puncture, a few drops of thin, yellowish serum was obtained. These tumors have 
been very troublesome for the past few years. They have caused severe dyspnoea. 
The physician who treated this boy in Hamburg believed that the growths contained 



*For complete list surgical works should be consulted. 

2 Read before the Section on Pediatrics., the New York Academy of Medicine, 
April 10, 1902. 

(842) 



SARCOMA OF THE THORAX. 



843 



pug. This statement was made to the family. The physician made an exploratory 
puncture and was rewarded by a few drops of thin, serous liquid, as in a puncture I 
made and obtained no pus. 

"The size of the growth as seen externally is about 15 centimeters in length 
and about 6 to 7 centimeters in circumference. (See Fig. 283.) There is marked 
dullness on percussion extending over most of the left side. The tumor is surrounded 
by a network of veins, intensely engorged with blood. There is mediastinal pressure. 
As far as can be seen and palpated, the growth occupies that region of the thorax 
usually occupied by the heart. The growth varies in size from week to week. 

"The heart has been pushed to the right side and occupies the right axilla. The 
apex beat is heard about two finger breadths below and to the right of the right 
nipple. (See figure 284.) 

"The pulse is 144, small, feeble, quite 
irregular and easily compressible. The 
respiration is irregular, of the Cheyne- 
Stokes type, and frequently sighing. It 
is usually about 50-52 in a minute; the 
temperature is always above normal and 
varies from 100° F. in the rectum, morn- 
ing, to 101 2 / 5 ° in the evening. There is 
always a febrile tendency. 

"There is constant dyspnoea and also 
extreme cyanosis of the lips, fingers and 
toes. The child is very pale and in a 
very anaemic condition. There is extreme 
pallor of the conjunctival membrane, the 
gums, and the mucous membrane of the 
lips." 

Owing to the extreme amount of 
weakness caused by anorexia, the child 
was compelled to remain in bed most of 
the time for the last year. Dyspnoea was 
so great that the child slept in a sitting 
posture. The child was very nervous and 
trembled when he was touched. He was 
very bright mentally. There was con- 
stant and rapid emaciation. Concen- 
trated food was given, which the patient 
took quite well. There was extreme 
hyperaesthesia of the skin. The digestion 
was quite good, and although the bowels 
moved sluggishly, they did not require 
much medicinal treatment. Fruit and fruit juices acted as laxatives. There was a 
curvature of the spine from left to right, most marked in the dorsal vertebra. The 
urine was examined several times. It showed no evidence of pus or blood, no 
albumin and no sugar. There was a slight indican reaction. No acetone, no casts, 
no morphotic elements, microscopically. 

The case was hopeless from a medical standpoint, as the growth was constantly 
increasing. The child suffered constantly from insomnia and great dyspnoea, requir- 
ing constant soporifics and narcotics. In spite of the grave prognosis, the family 
hoped that surgical measures might afford some relief. 




Fig. 283. — Spindle-cell Sarcoma. 
The prominence of the tumor shows 
by contrast the emaciation of the 
body. (Original.) 



844 



ABNORMAL GROWTHS. 



As the tumor frequently appears to show a distinct pointing, this latter 
condition suggesting fluid, an anaesthetic was given with the assistance of Dr. J. W. 
Wurthman. The anaesthetic was badly borne and I succeeded with difficulty in 
making two exploratory punctures. 

An x-ray examination, to verify the clinical data, was made by Dr. C. Beck, to 
whom the case was referred. The heart could be plainly seen pulsating on the right 





Fig. 284. ■ — -Anterior View of the Tumor. Showing also the position of the 
displaced heart and the enlarged veins. (Original.) 



side. No definite satisfactory data could be learned concerning the tumor, on 
account of the restlessness of the patient, and the child was removed to St. Mark's 
Hospital and operated. The child died soon after the operation. 

A specimen of the tumor, removed during the operation,, was sent by me to Dr. 
Mandlebaum, for a pathologic examination. He reported the tumor to be a spindle- 
cell sarcoma in a rather active state of growth, on account of the large number of 
mitoses present. The fluid contained simply red blood cells and no pus. 



HYPERNEPHROMA. 845 

Sarcomatous growths in children are quite rare, though met with from 
time to time. Thus Mauderli, in the Children's Hospital cf Basle, Swit- 
zerland, reports for the last twenty years that he treated a total of 10 
patients : 7 boys and 3 girls, of whom 4 were under 3 years of age, 3 were 
between 3 and 6 years, 1 was between .6 and 9 years, and 2 were between 
9 and 12 years. 

As but one case of malignant sarcoma was met with in this hospital 
in the course of the last twenty years in children as old as the case here 
reported by me, I feel justified in adding mine to those already recorded. 

The interesting points about my case were: (1) The displaced heart, 
the heart being immediately behind the right nipple. The pulsations and 
apex-beat could be distinctly felt and seen about two finger-breadths below 
the right nipple. (2) The intense dyspnoea caused by pressure of the 
tumor. (3) Constant cyanosis and oedema of the limbs, due to interference 
with the return circulation to the right side of the heart. 

Carcinoma. 

Carcinoma is occasionally found in children. Malignant growths of 
this kind have been diagnosed and verified by microscopical examinations. 

Hypernephroma. 

Literature records many cases of hypernephroma in children. The fol- 
lowing case 1 was seen by me in a boy 16 years of age: The case was brought 
to me with a history of hematuria. The bloody urine was noticed several 
weeks, and was probably due to injury caused by carrying some boxes, while 
working on a farm. No apparent discomfort nor pain was evidenced for 
many weeks, when a small swelling developed over the region of the spleen. 
Subjective symptoms, such as pain, were described and there was a slight 
rise in temperature. The swelling increased from day to day. A radiogram 
was taken by Dr. Caldwell. The diagnosis of tumor was made and the pa- 
tient was operated by Dr. John Erdman. The tumor was removed and 
proved to be a hypernephroma. Eadiograms of the long and flat bones 
revealed a series of tumors in the spine, scapula, and femora. 

The patient died of emaciation and exhaustion within a year. 

Lipoma. 

Fatty growths are occasionally seen in children. They occur on the 
scalp, on the back, and I have seen them on the buttocks. They require 
the same -treatment as fatty growths in adults. (See article in the section 
on "New-born Baby" on "Congenital Sacral Tumor.") 



1 For complete clinical history of this case see Archives of Pediatrics, Novem- 
ber, 1914. 



846 



ABNORMAL GROWTHS. 



En-ohondromata. 

These hard growths are usually found on the fingers and toes. They 
are found in the neighborhood of the joints, with which they are closely 
allied. A case of this kind which had several tumors removed occurred in 
my practice: — 

Mary B., 10 years old. 

Familty History. — Father healthy. Mother died of carcinoma of the uterus. 
Has one sister, who is healthy and married. 

Patient's History. — Was breast-fed during infancy. Suffered with no gastric 
or enteric disorders. Had measles when several years old. Is not subject to any 
chronic disease. Her extremities are normal excepting the affected hand. The 



■ 


BHH ^HHHH 



Fig. 285. — Enchondromata Involving the Thumb and 
Index Finger. (Original.) 

mother stated the tumors had been present soon after birth. They were not painful, 
nor did they cause discomfort, so nothing was done until the child reached this age. 
The case was referred by me to the surgical service of Dr. S. M. Landsman, who re- 
moved the growths. The case made a perfect recovery. 



Spina Bifida. 

Abnormal growths are frequently found in the lumbar region asso- 
ciated with the spinal cord. They are frequently seen in cases of hydro- 
cephalus. A case of spina bifida is reported in the chapter on "Malforma- 
tions of the Spine." 

Angeioma. 

Angeioma. — Large vascular growths are occasionally seen in children. 
A case of this kind was seen by me, which I describe in the chapter on the 
"New-born Baby," page 57. 



GRANULOMATA. 847 

Papillomata. 

This growth is occasionally seen in the larynx of infants and children. 
It may be congenital. 

Symptoms. — Marked dyspnoea is usually a prominent symptom. This 
dyspnoea increases with the enlargement of the growth. There is also a 
husky voice, which increases in severity. The symptoms are very marked 
at night, but are much less, and frequently disappear entirely, during the 
day. Cough may also be present, but no expectoration. There is no fever. 
The diagnosis is usually made by a laryngoscopic examination. When the 
same symptoms appear for weeks and months, a laryngeal growth should 
be suspected. 

Treatment. — Removal of the growth with an anaesthetic is absolutely 
necessary. The danger in removing the growth should always be borne in 
mind; hence the surgeon should be prepared to perform a tracheotomy if 
necessary. Intubation of the larynx will relieve the difficult breathing; at 
the same time there is danger of pushing some of this growth with the tube, 
thus obstructing the caliber of the same. Relapses are common. 

Granulomata. 1 

These growths are frequently seen at the site of the wound following a 
tracheotomy. They resemble a mass of exuberant granulations. 

Prof. A. Rosenberg, of Berlin, collected 231 cases of laryngeal tumors 
in children. Some of them were subjected to tracheotomy; others received 
endo-laryngeal treatment preceded by tracheotomy. In another series of 
cases persistent endo-laryngeal treatment was resorted to without perform- 
ing tracheotomy. This latter method yielded the better results. 



In Part II, page 35, will be found article on "Granuloma. 



PART XL 

DISEASES OF THE SPINE AND JOINTS. 



Pott's Disease. 3 



This disease derives its name from Percival Pott, who described it 
in 1779. "It is a chronic destructive process which begins in the bodies 
of the vertebras. The bodies of the vertebras support the weight of the body. 
As the disease progresses the weakened parts give way, and the upper seg- 




Fig. 286.— Poll V D's- 
ease ( Langerhans ) . Ky- 
phosis of dorsal vertebrae, 
the result of caseous tu- 
berculous periostitis and 
osteomyelitis. Destruc- 
tion of three thoracic ver- 
tebrae. Two-thirds nat- 
ural size. 



ment inclines forward. An angular posterior . projection, kyphosis, is 
formed which is the characteristic deformity of the disease." 

Etiology. — "Pott's disease may appear at any period of life, from 
earliest infancy to old age, but like all forms of tuberculosis of the bones, 
it is most common in the first ten years of life, and 50 per cent, of the 
cases begin between the ages of 3 and 5 years, inclusive. 

"The lower segment of the spine, including the dorso-lumbar region, 
is most often involved. Cervical disease is, relatively infrequent (cervical, 



1 The table of differential points between Pott's Disease and Rickets will be 
found on page 321. 
(848) 



POTT'S DISEASE. 849 

7 1 / 2 per cent.; dorsal, 68 per cent.; lumbar, 24 per cent.). The death 
rate is at least 25 per cent. The course of the disease is most protracted in 
the middle region; it is shortest in the cervical region, its duration vary- 
ing in favorable cases from two to five years. 

"When the local resistance overcomes the tendency to degeneration, 
the process of repair begins. The tuberculous products are absorbed or 
enclosed, and ankylosis between the two segments of the spine is estab- 
lished by means of a union, in part fibrous, cartilaginous, and bony. Firm 
union is long delayed, and the deformity may increase long after the 
disease has become inactive" (Whitman). 

Pathology and Bacteriology. — "The first indications of disease are 
most often found beneath the fibro-periosteal layer of the anterior longi- 
tudinal ligament. From this point the granulation tissue advances along 
the course of the blood-vessels into the adjacent bone, extending from 
one to another until several bodies are more or less involved. The disease 
is accompanied, in many instances, by an abscess, which may be of suffi- 
cient size to cause special symptoms; or the tuberculous process may find 
its way to the posterior part of the vertebral bodies and thus involve the 
spinal cord, causing paralysis. Abscess is most common as a complication 
of disease of the lower part of the spine, where it may be detected in at 
least 50 per cent, of the cases. Paralysis most often complicates disease 
of the upper dorsal region, appearing in about 10 per cent, of the cases 
in which this part of the spine is involved. The primary infection is no 
doubt due to the entrance of the tubercle bacillus." 

Anatomical Landmarks. — "The atlas is on a line with the hard palate. 
The axis is on a line with the free edge of the upper teeth. The transverse 
process of the atlas is just below and in front of the tip of the mastoid 
process. The hyoid bone is opposite the fourth cervical vertebra. 

"The cricoid cartilage is on a line with the sixth cervical vertebra. 

"The upper margin of the sternum is opposite the disc between the 
second and third dorsal vertebra?. 

"The junction of the first and second sections of the sternum is op- 
posite the fourth dorsal vertebra. 

"The tip of the ensiform cartilage is opposite the lower part of the 
body of the tenth dorsal vertebra. 

"The anterior extremity of the first rib is on a line with the fourth 
rib at the spine, the second with the sixth, the fifth with the ninth, the 
seventh with the eleventh. 

"The scapula covers the second and the seventh ribs, its lower angle 
being opposite the center Of the eighth dorsal vertebra. 

"The root of the spine of the scapula, the glenoid cavity, and the 
interval between the second and third dorsal spines are in the same plane. 

"The most constant landmark from which to count is the spinous 



850 DISEASES OF THE SPINE AND JOINTS. 

process of the fourth lumbar vertebra, which is on a line with the highest 
point of the crest of the ilium. The umbilicus is near the same plane. 

''The tip of the coccyx is opposite the lower border of the symphysis 
pubis." 

Symptoms. — If the upper part of the spine is affected, a stiffness of 
the neck usually exists. If the lower part of the spine is affected, limping 
will be noticed, hence awkwardness in walking in very anaemic children 
should always be looked upon as suspicious. 

"The limitation of motion due to muscular spasm, to pain; and to the 
local disease is an important factor in diagnosis. This, together with the 
deformity, may be demonstrated by bending the patient's body directly 
forward to the fullest extent. An object is next placed on the floor, and 
the patient is directed to pick it up. If this is done awkwardly by squat- 
ting or kneeling, it demonstrates weakness and stiffness. The patient 
should next be placed prone upon a table, and the surgeon should test the 
flexibility of the spine by lifting the legs and swaying the body from side 
to side. The range of extension at the hips may be tested at this time by 
holding the pelvis against the table with one hand, while the thigh is over- 
extended with the other. This is the test for the slight degree of psoas 
contraction that is often present on one or both sides in disease of the 
lower region. 

"The flexibility of the upper part of the spine may be tested by vol- 
untary and passive movements of the head in various directions, and the 
range of motion of the occipito-atlo-axoid joints by holding the neck while 
the patient nods and turns the head from side to side. 

"The character and the extent of the deformity, if it be present, should 
next be investigated. Note the contour of the spine. Any change from 
the normal are, in childhood, suspicious circumstances. Note the elastic- 
ity of the spine. If when the child is bent forward the spine forms a long, 
regular, even curve, disease is unlikely. If there be a break in the outline, 
and if one part remains rigid and another bends, disease may be suspected." 

Pott's disease in the lower region of the -spine presents the following 
characteristics : — 

1. Pain.-. — The pain is referred to the lower part of the abdomen, to 
the genitals, to the loins, or to the thighs. 

2. Gait. — The waddling gait which has been described under general 
symptomatology is characteristic of disease in this region. In some cases 
there is a limp. 

3. Attitude. — Usually an abnormal erectness and sometimes an ex- 
aggerated lordosis; in some instances a lateral inclination of the body. 
Unilateral psoas contraction and the attendant limp are often present. 

4. Stiffness. — Muscular rigidity of the lumbar region interferes 
directly with almost every attitude and movement. The effect of this 



POTT'S DISEASE. 851 

stiffness and of the accompanying weakness may be demonstrated by the 
popular method of asking the child to pick up a coin from the floor. In 
this region of the spine the symptoms are usually well marked before the 
stage of deformity, flexion of the legs, the effect of psoas contraction, and 
abscess are present in perhaps a third of the cases. 

Pott's disease of the middle region is characterized by the following 
peculiarities : — 

1. Pain is referred to the lateral region of the thorax or to the front 
of the body. It is a common symptom. It is noted after sudden move- 
ments or after compressing the chest, as when the child is suddenly lifted 
from the floor. 

2. Respiration. — If the disease is at all active, a grunting respiration 
is usually present, especially after exertion. This is the most characteristic 
of all symptoms, especially so in young subjects. 

3. Attitude. — This is not always distinctive, but usually there is a 
peculiar shrugging squareness of the shoulders; occasionally a lateral in- 
clination of the body. The head is often inclined backward. The neck 
seems short on account of the elevation of shoulders. 

4. Deformity. — The deformity is usually prominent and it appears 
early in the disease. 

5. Complications. — The most common complication of dorsal disease 
is paralysis, abscess being less frequent than in the lumbar region. Flat 
chest and chicken breast may be secondary deformities. 

Pott's disease of the upper region presents the following peculiari- 
ties : — 

1. If the uppermost cervical vertebra? are diseased, the pain is referred 
to the head, particularly to its lateral and posterior aspects. In disease of 
the middle cervical region it is referred to the neck, or to the shoulders 
or chest. 

2.- The weakness and stiffness are manifest by the attitude. The head 
cannot be turned freely. If the disease be in the occipito-axoid region, 
the nodding and rotary motions are restricted. The chin is often depressed 
and slightly turned to one side. Lateral distortion resembling torticollis 
usually occurs when disease is nearer the middle of the cervical region. 

3. The bony deformity is often slight or absent, but thickening of the 
tissues about the spine and local sensitiveness to lateral pressure are usu- 
ally present. Eetro-phar} T ngeal abscess is not uncommon when the atlo- 
axoid region is involved. 

Complications. — (a) Abscess; (b) Paralysis: About 25 per cent, of 
all cases have abscess. An abscess situated in the atlo-axoid region often 
burrows into the retro-pharyngeal space. It may involve the cranial cavity 
when this occurs; s} T mptoms of meningitis will be noticed. When an 
abscess forms from disease of the middle cranial region it usually opens 



852 DISEASES OF THE SPINE AND JOINTS. 

on the side of the neck, before or behind the sterno-cleido mastoid region. 
When abscess follows disease in the dorsal region it burrows through the 
thorax. It can be detected by the physical signs accompanying pain (see 
chapter on "Empyema"). 

When it burrows downward it may give rise to an iliac or lumbar ab- 
scess. "In disease of the lumbar region, the abscess, if superficial to the 
ilio-psoas muscle, may point in the neighborhood of the anterior superior 
spine, or pass through the inguinal ring. The true psoas abscess first dis- 
tends the iliac region, and then passing into the thigh, appears in Scarpa's 
space. In large abscesses of this character the pus may find an exit in the 
loin at the triangle of Petit, or in the gluteal region through the sacro- 
sciatic foramen. 

"In rare instances the abscess may find an opening within the body, 
and burst into the lungs, the intestines, or elsewhere. 

"As a rule abscess causes but little difficulty in diagnosis, because it is 
a late symptom, appearing after the diagnosis of Pott's disease has been 
established. It is more often an early symptom in the upper and lower 
regions of the spine, but in any event it is always accompanied by symp- 
toms of the underlying disease of the spine/ 7 

Paralysis. — The symptoms of Pott's paralysis are "an awkward stumb- 
ling gait, weakness, and finally an inability to stand. The lower limbs are 
'stiff at times. The reflexes are increased. Control of the bladder may be 
retained, but often there is active incontinence; that is, the bladder emp- 
ties itself from time to time. If the pressure is directly upon the reflex 
centers in the lumbar enlargement, there may be passive incontinence or 
dribbling of urine. If the pressure is below the reflex centers, the bladder 
is not affected, and the symptoms of numbness and weakness resemble those 
caused by neuritis." 

Differential points concerning abscess : — ■ 

1. Abscess of the cervical region must not be confounded with the 
symptoms of enlarged tonsils, adenoids, or with so-called croup. It must 
also be 'distinguished from the simple acute abscesses of this' region. 

2. Abscess of the thoracic region is to be distinguished from those 
secondary to disease of the lung or of the chest wall. 

3. Abscess in the loin or inguinal region may be mistaken for the 

acute or chronic abscess due to : — 

, ■ , -r. . -. ' ... ( These are usually of acute onset and are ae- 

(a) Perinephritis, J . J . 

) companied by constitutional disturbances. 

{There may be secondary rigidity of the spine, 
but no deformity, as is usual in Pott's dis- 
ease at the stage of abscess formation. 

(c) Sacral or iliac disease. The -symptoms of Pott's disease are lacking. 

(d) Hernia. 



POTT'S DISEASE. 



853 



The paralysis of Pott's disease must be distinguished from 

1. Simple weakness. 

2. Injury to the cord. 

3. Tumors of the cord. 

4. Syphilitic disease of the cord. 

The weakness and stiffness caused by Pott's disease in the lower region 
may be simulated by lumbago, rheumatism, sciatica, and by the effect of 
injury or strain. Lumbago, rheumatism, and sciatica are uncommon in 
childhood. They are usually of sudden onset. Sciatica is usually uni- 




Fig. 287. — Pott's Disease. Case of Harry F. (Original.) 



lateral; the pain of Pott's disease is usually bilateral. Strains and other 
injuries have, as a rule, a well-defined history. 

Prognosis. — This should be cautiously given. While most cases seen 
by me ended fatally, several cases improved and recovered entirely. Years 
of patient treatment are necessary, and occasionally the most severe cases 
may end in recovery. 

Harry F., 4 years old. 

Family History. — Father and mother are unhealthy, weak and very poor. One 
child has died of summer complaint. Another, two years younger, is inclined to 
cough, and was operated by me for empyema. 



854 DISEASES OF THE SPINE AND JOINTS. 

Personal History. — The child was born and has since then lived in a tenement 
house, in a densely populated section of the city. He was a bottle-fed infant, and 
has been constipated since birth, although he suffers with diarrhoea in summer. 
Has always been a frail and sensitive child. Has had measles and bronchitis, and 
is constantly troubled with some catarrhal affection. The child was late in walking, 
late in talking, and late in dentition. The general development shows backwardness 
when compared with a normal child. A slight deformity of the spine was first 
noticed when the child was about 2 years old. It has increased in prominence since 
that time. There is no distinct evidence of tuberculosis that can be made out in the 
lungs. The glands are not enlarged, there is no cough or expectoration. No evidence 
of fever. 

The treatment consisted in giving codliver-oil and creosotal internally from 2 
to 5 drops, three times a day. Friction of the body and general hygienic measures 
were instituted. Great stress was laid on the nourishment of the body. Cream, 
butter, eggs, cereals, and vegetables have been given constantly. 

Orthopaedic Treatment. — For the relief of the deformity, a supporting brace 
fitted to the body like a corset, similar to a Bradford frame, had been used for over 
six months with little improvement, therefore the case was sent to Dr. Ashley for 
a plaster-of-Paris corset. This treatment has been very successful, and the child 
is progressing favorably. 

Treatment. — When pus is present nothing but surgical treatment 
should be considered. Surgical treatment is not always necessary. The 
majority of cases require support by means of (a) spinal splint; (b) spinal 
brace; (c) plaster jacket. 

Either of these must be properly applied by a competent surgeon. I 
have seen some very disagreeable accidents clue to a too tight plaster corset. 
For details in connection with the application of braces or plaster jackets 
the reader is referred to text-books on orthopaedic surgery. 

Medicinal Treatment. — This consists in giving restoratives such as 
codliver-oil, iron, and arsenic. Creosotal can be given with the codliver- 
oil. A rigid diet such as cream, butter, milk, cereals, eggs, vegetables, and 
fruits is indicated. 

If the child lives in the city a change to the seashore or to the moun- 
tains will sometimes improve the chances of recovery. 

Flatfoot in Children. 

Children are not born flatfooted. Very heavy children are predis- 
posed to flatfoot, especially if rickets is present. Laxity of the knees is 
usually found associated with this condition. 

Treatment. — Careful orthopaedic treatment is necessary. This usu- 
ally consists in wearing a properly fitting shoe in which the arch is sup- 
ported with the aid of a stiff steel or celluloid plate. At times a soft pad 
of felt only is necessary. 

E. W. Lovett, of Boston, has contributed to the literature of this 
subject, and the reader is referred to his writings for details on this matter. 



SCOLIOSIS. 855 

Spinal Curvature. 

The spine of a new-born infant is almost straight, but from the time 
the child begins to walk erect, curvatures arise in the direction forward 
and backward which are normal and physiological, viz., a curvature with the 
convexity forward in the region of the neck, backward in the dorsal region 
and forward in the lumbar region. 

Kyphosis. 

Kyphosis is also known as round-back. It is an increase in the normal 
curvature in the dorsal region of the spine. It is a non-inflammatory con- 
dition and is amenable to treatment. The increase in the curvature back- 
ward is called round-back, kyphosis arcuata, increase in the curvature 
forward, saddle-back, lordosis. The cause is usually faulty position assumed 
at school or at home, and associated therewith weakness of both muscles 
and bones. 

I have elsewhere in the article on rachitis, also in the article on Pott's 
disease, described this condition. 

The treatment depends on the cause. If it is due to rachitis, restorative 
treatment is indicated. Iron, hypophosphites of lime and soda, and codliver 
oil "are the drugs to be given. In addition to drug treatment, fresh air 
and out-door life must be given before g} r mnastic exercises are considered. 
Deep breathing with arms raised and extended forward and backward, in 
a cool room, should be a daily routine. The exercises should not be carried 
to a point of exhaustion; usually ten to fifteen minutes is sufficient to 
produce a good reaction. 

If the kyphosis is due to tuberculosis of the spine an open-air life 
should be recommended. The treatment of tuberculosis in general applies 
very forcibly to Pott's disease, but we must remember that, be the kyphosis 
due to an atony of the muscles or to a general systemic weakness such as 
rachitis, such cases will relapse unless the daily exercise is continued. 

Scoliosis. 

Every permanent deviation to the side, in the spine, is called lateral 
curvature or scoliosis, and is the form most commonly met with of all 
deformities of the spine. 

Scoliosis may be called cervical, dorsal, or lumbar scoliosis, depending 
upon which part of the back is bent. The curvature may include only a 
few vertebras, or the spine in its entirety. Two or more curvatures may 
simultaneously be found in the same person. Scoliosis can, further, be 
right-sided or left-sided, according to the convexity of the lateral curvature. 

Scoliosis has a pretty constant course. Although no exact limit can 
be fixed, scoliosis may be suitably divided, from a symptomatological point 



856 DISEASES OF THE SPINE AND JOINTS. 

of view, into three degrees of development. The slightest forms of scoliosis 
can develop into the most severe: it is impossible, however, in every case 
to foretell whether a scoliosis will be stationary at a certain stage or whether 
it will further develop itself. 

A scoliosis of the first degree may, to the unpractised, be difficult to 
detect, as no clear curvature of the spine can be observed. The existence of 
the scoliosis is characterized by a slightly forward arching or bulging-out of 
the lateral contour in the region of the chest. Scoliosis of the first degree 




Fig. 288. — Scoliosis due to faulty Fig. 289. — Same girl; arms folded. Note 

posture at school. difference in scapulae. (Original.) 

is noted whenever the patient takes a standing or sitting position, but it 
disappears in a hanging or lying position. A scoliosis of the second degree 
can also disappear, as long as the patient takes certain positions or per- 
forms certain movements which counteract the form of scoliosis in ques- 
tion; pressure on the convexity of the curvature may also bring the spine 
back to a straight position. A scoliosis of the first degree is called simple, 
primary, or C-formed. Generally the primary scoliosis appears as a right- 
convex dorsal scoliosis or as a left-convex lumbar scoliosis. 

A scoliosis of the second degree arises in the following manner: that 
to the primary curvature, after a time, another unites itself — a secondary, 



SCOLIOSIS. 857 

compensatory or so-called anti-curvature; in consequence of this formation 
the scoliosis has become S-formed. A scoliosis of the second degree differs 
also from one of the first degree in that the curvature does not now quite 
disappear in a hanging or lying position, not always in taking certain bodily 
positions, nor by means of pressure on the convexity of the curvature, but 
the spine is, however, still mobile ; so that the curvature in the given position 
is diminished, in consequence of which the scoliosis can be treated success- 
fully also in this stage. 

The third degree of development in scoliosis is arrived at by the for- 
mation of several deformities of the spine itself and of the adjacent bones, 
whereby the scoliosis becomes permanent or fixed, so that the curvature 
of the spine itself in this stage cannot be treated. The attendant symptoms 
of shortness of breath, disordered circulation and intercostal neuralgia must, 
on the other hand, often be treated. The scoliosis in this degree is called 
kypho-scoliosis. 

When a scoliosis develops itself, the vertebrce undergo a most radical 
change from a pathological point of view, and this change is not easy to 
detect, but the alterations in the ribs, with respect both to form and position, 
is the surest symptom from a purely clinical point of view. 

Through the uneven pressure to which the vertebras are exposed in a 
scoliotic spine, the side directed toward the concavity of the curvature will 
be slower in growth, while the side directed toward the convexity will de- 
velop itself normally. The consequence of different development will be 
that the vertebrce will gradually assume the form of a wedge, with the point 
of the wedge directed toward the concave side of the scoliosis. 

From a clinical point of view the greatest change is to be found in 
the ribs, so that an incipient scoliosis is most easily detected in the change 
the chest undergoes in its entirety. The special alterations in the ribs ac- 
company those of the vertebras. For example, those ribs that correspond 
to the convexity of the scoliosis will be , separated from each other, while 
those that correspond to the concavity will become compressed and even 
atrophic. The ribs on the convex side will develop a considerable increased 
flexion of their posterior extremity, and diminished flexion of their anterior 
extremity. 

A change of position of the sternum does not so frequently occur, but 
in the above-named form of scoliosis, in some cases, the lower end of the 
sternum deviates toward the left, i.e., toward the concavity of the curvature. 

In a well-marked scoliosis the pelvis will, in consequence of the uneven 
weighing, also be crooked and asymmetrical, especially in more severe 
lumbar scoliosis, as then the os sacrum also takes part in the spinal 
curvature. 

As regards the muscles of the spine, the change in the same was for- 
merly considered to be very considerable, and it has even been considered 



858 DISEASES OF THE SPINE AND JOINTS. 

as being the origin of the scoliosis. In well-marked scoliosis the long dorsal 
muscles that run over the convexity of the curvature become stretched and 
even atrophic, perhaps mostly in consequence of the rigidity of the spine 
and the consequent inactivity of the muscles. 

The shoulder-blade is removed from its normal position by the change 
in the chest. The shoulder-blade on the convex side is pushed forward 
by the increased posterior bulging out of the ribs in the direction upward, 
backward and outward from the middle line ; the shoulder-blade on the con- 
cave side sinks, because the ribs on this side will be less curved posteriorly, 
and the shoulder-blade draws nearer to the middle line. 

When muscular weakness due to faulty nutrition exists, we have a 
predisposition which asserts itself in a faulty posture, such, for instance, 
as an incorrect writing position or various kinds of female handwork. 
Infantile paralysis, by virtue of its arrested development, will cause a 
shortening of the affected leg, and thereby be a factor in the development 
of a spinal curvature in the lumbar region. In children, faulty position in 
standing, as, for example, standing on one leg or sitting so that the body 
weight rests on one buttock, is a common cause of lumbar scoliosis. Eulen- 
burg states that rachitic scoliosis is found in 50 per cent, of cases during 
the second year of life, 25 per cent, during the third year, and from the 
fourth year a decrease down to the sixth year. When a general rachitis 
exists or when we note the presence of a pigeon-breast or a funnel-shaped 
breast, in such children one is likely to meet with a rachitic scoliosis. 
Pleurisy with effusion is another cause of scoliosis. If the effusion remains, 
or results in a pyothorax from the shrinking of the lung and sinking of 
the diseased half of the chest, there will result a scoliosis in the dorsal 
region, having the concavity toward the healthy side. 

A radiograph is the most exact method of recording the curvature, and 
studying the therapeutic results. 

Prophylaxis. — In the very young child it is almost impossible to prevent 
scoliosis when the bodily structure is weak, as in rachitis. In the older 
child, where the effects of faulty position in sitting or standing can be 
explained, it is frequently possible to prevent scoliosis. 

Girls between the ages of 8 and 15, especially those who desire to 
shine by contrast in society, are frequently overburdened with home-work, 
needle-work, painting or piano practice which frequently requires hours of 
patient sitting. It is this class of cases in which, by overstrain, the spine 
is weakened and curvature results. 

Treatment. — Only simple curvatures, or those resulting from weak 
muscles, faulty habits or position shall be considered. Curvatures resulting 
from congenital or pathologic anomalies, caries of the spine, tuberculosis, 
etc., should be sent to the orthopedist. 

Begin with good breathing exercises. Train the habit of posture. . Give 



PLATE XLIII 











1 


, v^^^BylL ^^^^^|Bk 













X-ray of Congenital Dislocation of Hip. 



SCOLIOSIS. 



859 



general light exercises for muscle building and stimulation of the circulation, 
respiration, and digestion. 

It is impossible to lay down rules which can apply to every case of 
scoliosis. Thus, a scoliosis of the first degree will do very well by strictly 
supervising and preventing the faulty position while at school or at home. 
In addition thereto, gymnastic exercises to develop and strengthen the 
muscles of the back and chest will quickly solve this problem. In addition 
to the mechanical treatment, restoratives such as iron, hypophosphites, and 




Fig. 290. — In cervical scoliosis, side 
flexion in the region of the neck can 
best be obtained by having a boom or 
crutch placed under the arm-pit, at a 
height to obtain a firm' support. This 
position should be retained from three 
to five minutes. 




Fig. 291. — Exercise adapted for 
lateral curvature. Patient sits on a 
stool in such a manner that the anterior 
bent leg rests on the floor, while the 
whole of the buttocks and the upper leg 
rests on the stool. This position is 
maintained while ten to twenty deep 
breaths are drawn. 



codliver oil should be given. Fresh air and out-door exercises should form 
the basis for the tonic which will help to assimilate food and thus strengthen 
the bone and muscle. 

A scoliosis of the second degree or scoliosis of the third degree requires 
not only the restorative treatment above mentioned, but, in addition 
thereto, mechanical treatment. Such mechanical treatment consists in the 
temporary support given to the spine by plaster-of-Paris cast, or, in many 
cases, the curvature can be corrected with the aid of a spinal brace. Such 
brace or plaster-of-Paris support is utilized to correct the curvature, and 



860 



DISEASES OF THE SPINE AND JOINTS. 



when the mechanical appliance is removed gymnastic exercises are given to 
restore the tone of the muscles and aid in the circulation which is disturbed 
while the mechanical appliance is used. The gymnastic treatment should be 
supported by massage. 

Hanging is especially indicated in cases of kyphosis. The spine and 
spinal muscles are stretched into their normal position by the weight of 
the patient's body. 




Fig. 292. — Sitting-hanging with rod 
is principally used for round-back, but 
also to advantage in scoliosis. The 
nurse stands behind the patient and 
offers slight resistance to the rod as the 
patient stretches his arms, and resist- 
ance is still offered when the arm ex- 
tension has reached its maximum, so 
that the patient is obliged to keep a 
stretched and corrected bearing of the 
body. This position should be main- 
tained from one-fourth to one-half min- 
ute. Repeat ten to fifteen times. 




Fig. 293. — Resistance, especially 
adapted for young children. The pa- 
tient places his hands in the groin with 
the four fingers together forward, the 
thumbs directed backward, thus, by 
putting the extensors of the arms into 
action, causing a lifting of the trunk, 
while stretching takes place at the 
same time in the spine. The mother or 
nurse stands at the side of the patient 
and sees that he carries his shoulders 
backward as far as possible; slight 
pressure in the middle of the back and 
over the crown of his head encourages 
still greater exertion, i.e., the move- 
ment is changed from a purely active 
one to a movement of resistance. 1 



1 1 am indebted to Dr. Anders Wide's Hand-book of Medical and Orthopaedic 
Gymnastics, published by Funk & Wagnalls, for the illustrations in this article. 



HIP-JOINT DISEASE. 861 

The hands, separated from each other by the width of the shoulders, 
take hold of the pole or trapese, placed or held at such a height that the 
feet do not touch the ground when the arms, trunk, and legs are fully 
extended. 

With heels together and knees straight, have patient bend body for- 
ward until the hands touch the floor in front of the toes, or come as near 
to the floor as possible, then raise the body to standing position.' Eepeat 
slowly ten to fifteen times. 

Abbott 1 and others have advised an overcorrection of the curvature to 
secure normal conditions. Many orthopedists have told me that while this, 
is a painful method it has its advantages. Others have advised against the 
overcorrection. The method seems best adapted for the very young where 
marked elasticity of the spinal column still exists. 



Morbus Coxarius (Hip- joint Disease; Tubercular 
Hip- joint Disease). 

Coxitis, commonly known as tuberculosis of the hip-joint, is not easily 
diagnosticated in the primary stage. 

The age is no hindrance to the development of this disease, as it 
usually appears between the fifth and tenth years. 

Coxitis can be found in apparently healthy children showing no sign 
of scrofulosis. 

1. They complain of tenderness. 

2. Impediment of locomotion of the affected extremity. 

3. The change of the position. 

4. Local changes in the region of the joint. 

Symptoms. — The pain is one of the earliest symptoms and expresses 
itself by a feeling of tenderness in the affected joint or in the knee. The 
knee is quite characteristic in this affection and serves a good center for 
deception. In the knee no changes are directly noticeable; there is no 
impediment to locomotion. When the pain can be located in the knee- 
joint the pathological process in the hip-joint is usually fully developed. 
When children complain of pain in the knee-joint, it is always wise to 
examine the hip. One of the most characteristic symptoms is the in- 
variable cry at night. 

The child will cry frequently and will suddenly awaken at night, with 
pain along the thigh not pointing to a distinct spot, but showing that the 
pain is diffused along the leg; this symptom is rarely absent in true 
coxitis. 



1 Abbott, N. Y. Medical Journal, April 27, 1912. 



862 



DISEASES OF THE SPINE AND JOINTS. 



At the earliest stage of coxitis the pain is trivial, but instinctivel}- 
the patient tries to use the healthy limb and not the unhealthy one. This 
is one of the causes of limping. When tenderness can actually be located, 
then locomotion is also limited. When this exists, difficulty in abduction 
and adduction appears. 

When examining by grasping the affected limb with one hand and 
supporting the small of the back with the second hand, a distinct resistance 
of the muscles can be felt. 





Fig. 294. — Tuberculous Coxitis — Front 
View. 



Fig. 295. — Tuberculous Coxitis — Side 
View. 



TUBEECULOUS COXITIS (DOUBLE). 

C. M., 10 years old, girl. Duration of disease, in left hip six years, and 
right hip five years. No history of exanthematous diseases. Treated at the Post- 
graduate for seven months in orthopaedic ward. An erasion of disease in left hip 
at this time. 

Examination. — Right hip flexed to 90°, left hip flexed to about 95°. Right hip 
in adduction 10°, distinct spasm of the adductor muscles. Left hip in adduction 35°, 
slight spasm of the adductor muscles. Motion in right hip 10°, in left hip 20°. 
Right great trochanter two inches above Nelaton's line. Apparently no abscesses. 
Left trochanter almost denuded by erasion, only slightly above Nelaton's line. 
Many abscess scars, all healed. 

Treatment. — Modified Gant on right side, forcible correction of the left side, 
with tenotomies. 



Congenital Dislocation of the Hip. 

This is the most frequent form and the most important of the con- 
genital dislocations.. 



Illustrations Figs. 294 and 295 are furnished through the courtesy of Dr. 
Dexter Ashley. 



CONGENITAL DISLOCATION OF THE HIP. 



863 



Etiology.— Faulty development of the acetabulum and the head of 
the femur combined with laxity of the capsule and possibly pressure upon 
the flexed thigh are supposed to be the causes of this condition. The dis- 
placement is usually upon the dorsum, although it may take place forward 
or upward. It is most frequent in females. Whitman states that 85 per 
cent, occur in females. It is usually seen unilateral. I have seen many 
cases bilateral. Sometimes a peculiar family predisposition seems to exist, 
as several children in the same family have this deformity. 




Fig. 296. — Congenital Hip Dislocation. Cases occurred in the practice of 

Dr. Dexter Ashley. 



Symptoms. — Unilateral Dislocation-. — The child limps when it begins 
to walk. The abdomen is very prominent. There is an abnormal lordosis. 
The buttocks appear enlarged. The thighs are usually separated and there 
is an increased breadth of pelvis. Shortening is difficult to detect in the 
beginning of the disease, but if the child grows older and the condition 
has been neglected, then a shortening of several inches may sometimes be 
detected. Such children are easily fatigued. 

Bilateral Dislocation. — The pelvis is broadened and the thighs are far 
apart when the patient stands or walks. The limp is exaggerated and the 
child waddles. The lordosis is very marked. 



864 DISEASES OF THE SPINE AND JOINTS. 

Treatment. — Replacement by traction, by extreme abduction and 
flexion with prolonged fixation in the attitude of extreme abduction, known 
as the Lorenz treatment, is frequently successful. In some cases the 
above treatment is unsuccessful and a radical operation must then be 
performed. ' 

G. L., male, 9 years old; A. L., female, 6 years old; H. L., female, 4 years old. 
Three out of five children in one family, of Irish parentage. No< .previous history 
of lameness. 

G. L., double posterior dislocation; muscular; great telescopic motion; right 
side has a shortening of 2% inches, left side 2% inches, as per Nelaton's line; head 
and neck apparently well developed; thighs flexed, adducted and rotated inward; 
marked lordosis; walking ungainly and laborious; limited motion in abduction 
and extension; feet inclined to be flat; can stand in almost normal position except 
lordosis. Skiagraph reveals very well-developed neck on each side, the right inclined- 
to coxa varus; head on each side inclined to be conical; acetabula rather shallow, 
but well formed otherwise. Advised no operation as the child" was too old, and the 
circumstances of the family would not admit of good after-treatment. 

A. L., right posterior dislocation; distinct limp; limb carried slightly in ad- 
duction; shortening iy 2 inches; neck short and straight, or coxa valgus. Skiagraph 
verifies above observations, and shows an apparently poorly formed acetabulum, with 
considerable thickening. Preternatural mobility in all directions except abduction. 
Operation advised and performed. Transposition secured. 

H. L., 4 years old; posterior dislocation; % inch shortening; limp well 
marked; neck and head rather short but of normal angle; preternatural mobility in 
all directions except abduction. Skiagraph reveals short head and neck, apparently 
well-formed acetabulum. Operation performed. Very good result, but might have 
been improved upon if child had been brought in for after-treatment. 



Knee-joint Disease. 

This is a chronic tuberculous inflammation due to an osteitis of the 
femur or tibia. It may begin as a synovitis similar to hip-joint disease. 

Etiology. — Traumatism is usually the exciting factor, as in hip-joint 
disease. 

Pathology. — The pathological lesions are those of tuberculosis. The 
tubercle bacillus is usually found, although it may be absent. The lesions 
spread and sometimes cause complete destruction of the joint. A char- 
acteristic swelling noted in tuberculous knee-joint is caused by an infiltra- 
tion of the soft parts with a gelatinous substance which must be attributed 
to a tuberculous process. 

Symptoms. — Children old enough to complain will describe pain when 
moving the joint. A limp is noticed when walking. A swelling of the 
joint gradually appears. The knee assumes a flexed appearance which is 
quite typical of this condition. As a result of the swelling in the joint, 
motion is limited, and the pain at times is very severe. Fever may or may 
not be present. In a case seen by me recently, although a large quantity 



WRIST-JOINT AND ELBOW-JOINT DISEASE. 8G5 

of pus was present, no fever could be detected. This condition was one of 
the usual "cold abscess type." 

Diagnosis. — This depends on the limitation of motion, on the swell- 
ing, and on the pain. It does not resemble rheumatism owing to the affec- 
tion being limited to one joint. In rheumatism there is fever, at times 
very high fever, inflammation, swelling, and a sudden onset of symptoms. 
Just the reverse condition is found in knee-joint disease. 

Prognosis. — The prognosis as a rule is good. Fully 90 per cent, of 
cases recover, according to Moore. When, however, cases are neglected, 
ankylosis of the knee-joint results. 

Treatment. — Eest in bed, assisted by proper hygiene and a good sup- 
porting diet, constitute the general line of treatment to be pursued by the 
general practitioner. The ■ deformity requires careful orthopaedic treat- 
ment. A case of this kind usually requires a knee-splint or a plaster cast. 
It is self-understood that only one competent to do this should guide the 
treatment. For details regarding the application of knee-splints, etc., the 
reader is referred to works on orthopaedic surgery. 

Diseases oe the Ankle-joint and Tarsus. 

Tubercular disease frequently affects the ankle and tarsus. The same 
pathological manifestations described in hip and knee-joint diseases are 
found here. 

Symptoms. — As a rule a limp will be noticed. Associated with this 
there is swelling of the joint, limitation of motion, and in some cases fever; 
in other cases, atrophy of the muscles of the leg. The superficial veins are 
usually enlarged. 

Diagnosis. — The slow onset of the symptoms associated with swelling 
and the limp on walking will usually aid in establishing the diagnosis. 
It is important to exclude rheumatism by carefully examining other joints 
of the body. The diagnosis rests upon the disease being limited to one 
joint in addition to the symptoms above described. 

Prognosis. — The prognosis is usually good. Cases usually recover 
under proper management in six to nine months. 

Treatment. — The same treatment described in the article on knee- 
joint disease applies here. The parts should be given absolute rest. This 
can be secured by the use of plaster-of-Paris casts. The rest of the treat- 
ment is restorative. 

Wrist-joint and Elbow-joint Diseases. 

This condition is rarely met with in children. When, however, tuber- 
culous manifestations exist the symptoms are the same as described in 
other tubercular joints. 

55 



866 DISEASES OF THE SPINE AND JOINTS. 

Treatment consists in securing rest and immobility of the parts with 
the aid of plaster casts. Pus, when present, requires surgical relief. The 
outcome of these cases is as a rule good. 

Joseph S., 10 years old, has been under the treatment of Dr. Dexter Ashley, to 
whom I am indebted for the illustration. The child was in an extremely anaemic 
condition, heart and lungs normal, no evidence of tuberculosis/ Family history good. 
Local evidence of tuberculosis involving the elbow- joint, so-called bone tuberculosis. 
The boy was able to run about, and excepting this arm seemed to be in a fair physical 




Fig. 297. — Tubercular Elbow-joint. 

condition. A comparison of the healthy elbow-joint with the diseased joint is quite 
interesting. Dr. Ashley's treatment consisted in strict aseptic dressings, tight 
bandaging, a bandage to support the return circulation, and general restorative treat- 
ment. 

Acute Arthritis (Infectious Osteitis: Acute Purulent Synovitis: 
Acute Epiphysitis: Acute Osteomyelitis). 

This is an acute inflammatory condition involving a joint. It is 
always suppurative from the beginning; it is therefore a form of pyaemia, 
It is an infection originating at the bone in the medullary canal or in the 
joint. 



ACUTE ARTHRITIS. 867 

Etiology. — This condition may follow the acute infectious diseases, 
especially those which show a tendency to suppurative processes. It most 
frequently follows measles, scarlet fever, and empyema. 

There seems to be no reason to believe that this disease owes its exist- 
ence to syphilis, tuberculosis, or scrofulosis. Some authors state that a 
history of traumatism has preceded this infectious disease. 

Bacteriology. — Cultures taken of the purulent discharge usually show 
the presence of the streptococcus pyogenes or the staphylococcus. The 
point of entrance for the pathogenic bacteria may be either the skin, if 
abraded, the umbilicus, or the tonsil. In this manner the bacteria gain 
entrance to the circulation. 

Symptoms. — Distinct swelling of the joint can be made out, although 
the inflammatory condition is deep-seated. The joint is red and inflamed 
and has a glazed appearance. Fluctuation can be felt if properly palpated. 
The usual symptoms of inflammation, such as high fever and chills or 
rigors, are present. 

The joints most usually affected are best judged by studying Town- 
send' s collection of cases: — 

Hip 38 cases 

Knee 27 cases 

Shoulder 12 cases 

Wrist 5 cases 

Elbow 4 cases 

Ankle 4 cases 

Fingers 2 cases 

Toes 1 case 

Sternoclavicular 1 case 

Diagnosis and Differential Diagnosis. — The diagnosis is easily made if 
we remember the rapidity with which this condition develops. It may 
resemble rheumatism, but the acute onset with the fever and the suppura- 
tion makes it easy to exclude rheumatism. Syphilis may resemble arthritis, 
but the fever and suppuration are never present in syphilis. 

Prognosis. — If the disease extends rapidly death may occur in a few 
days. The outcome of the case depends on recognizing the disease in its 
early stages, and on the rapidity with which the suppurative condition is 
relieved. 

Treatment. — The treatment is surgical. With aseptic care and atten- 
tion to surgical detail, pus should be evacuated and the joint properly 
immobilized. To prevent deformity fixation of the joint should be remem- 
bered. Restorative treatment should consist in giving arsenic, maltine with 
hypophosphites, in addition to concentrated food and general hygienic care. 
The surgical treatment should be given into the hands of a surgeon. 



PART XII. 

MISCELLANEOUS. 



CHAPTER I. 

DIETARY. 

Beverages. 

Albumin Water. — Stir the whites of 2 eggs into % pint of ice-water, 
without beating ; add enough salt or sugar to make it palatable. Such a 
mixture is one of the best foods we have for substitute feeding an infant 
with digestive disturbances when we wish to temporarily stop all milk-food. 

Almond-milk. — Take two ounces of sweet almonds, scald them with boil- 
ing water ; after a few moments express them from the hulls ; then pour the 
hot water away. Put the blanched almonds into a mortar and pound them 
thoroughly, and add either 2 ounces of milk or 2 ounces of plain water. 
After this is thoroughly mixed, it is to be strained through cheese-cloth, 
and the strained liquid will be the almond-milk. 

Arrowroot Water. — Add 2 tablespoonfuls of arrowroot to 1 pint of 
water ; _allow it to simmer for half an hour, stirring it constantly. 

Barley Water. — Take a tablespoonful of pearl barley, grind it in a 
coffee-grinder, or pound it in an ordinary mortar; add 1 quart of cold 
water, and allow it to simmer slowly for about an hour. Strain and add 
enough water to make 1 quart. 

Beef Juice. — Expressed beef juice is obtained by slightly broiling a 
piece of lean beef and expressing the juice with a lemon-squeezer. One 
pound of steak yields 2 or 3 ounces of juice. This is flavored with 
salt and given cold or warm. Do not heat enough to coagulate the albumin. 
This is very nutritious and usually well taken. It may be given at the 
rate of a tablespoonful three times a day. 

Cocoa. 1 — For each large cup take a teaspoonful of cocoa and a tea- 
spoonful of sugar; mix to a paste with a little boiling water or ttiilk; add 
balance of milk or milk and water, as richness is desired. Let it boil a 
minute, as boiling improves it. 

Chocolate (Unsweetened). — For each breakfastcup take 1 division, 
break in small pieces, and allow to melt; add milk or milk and water, as 



1 A palatable and digestible form of cocoa is manufactured by Hershey, of 
Pennsylvania. 

(868) 



DIETARY. 869 

richness is desired. Stir constantly. Bring to a boiling point and set 
aside to simmer. Sugar to taste. 

Eggnog. — Heat some milk to a temperature of 150° F., but do not 
allow the milk to boil. When cold, beat up a fresh egg with a fork in a tum- 
bler with some sugar; beat to a froth, add a dessertspoonful of brandy, and 
fill up tumbler with the warm milk. 

Oatmeal Water. — Take a tablespoonful of ordinary oatmeal, and add 
1 pint of water. Allow it to simmer slowly for one hour and strain. Add 
enough water to make 1 pint. The same directions apply to making a 
household mixture of farina-water, and sago-water, using the same propor- 
tions as above. 

Rice Water. — One ounce of well-washed Carolina rice. Macerate for 
three hours at a gentle heat in a quart of water, and then boil slowly for 
an hour and strain. It may be sweetened and flavored with a little lemon- 
peel. Useful in diarrhoea, etc., when the flavoring is best dispensed with, 
and a little old cognac added. 

Yolk of Egg Lemonade. — Take the beaten yolk of 1 egg and add to 
it the juice of 1 / 2 lemon. Let stand five minutes, thus drawing off the raw 
taste of the yolk of egg. Add 1 teaspoonful of sugar and 8 ounces of water. 

White of Egg Orangeade. — Take the juice of 1 orange and 1 ounce 
of water, insert an egg whisk, and when the orangeade is in full agitation, 
add slowly the white of egg. Continue the whisking for two or three min- 
utes more. Add y± teaspoonful of sugar. 

White of Egg Lemonade. — Leftwich 1 advises the following for a nutri- 
tive drink for febrile and wasting diseases: — 

I£ Lemons 2 

White of eggs 2 

Boiling water 1 pint 

Loaf sugar to taste. 

The lemon must be peeled twice — the yellow rind alone being utilized 
— while the white layer is rejected. 

Place the sliced lemon and the yellow peel in a quart jug with 2 lumps 
of sugar. Pour upon them the boiling water and stir occasionally. When 
cooled to the ordinary temperature, strain off the lemons. 

Now insert an egg whisk, and when the lemonade is in full agitation 
add slowly the white of egg. Continue the whisking for two or three 
minutes more. While still hot, strain through muslin. Serve when cold. 

The white of egg will be found to impart a blandness which makes 
the addition of sugar almost unnecessary. 

This drink is very useful in the febrile diseases of children. It may 
be given simply as a lemonade, without mentioning the eggs, and will 

1 Edinburgh Medical Journal. 



870 MISCELLANEOUS. 

thus be readily taken by the children and difficult patients. It also pos- 
sesses antiscorbutic properties, which replace those lost from milk by boil- 
ing and sterilizing. 

Soups and Broths. 

Chicken Broth. — Cut up a small chicken, put bones and all, with a 
sprig of parsley, salt, 1 tablespoonful of rice, and a crust of bread, in a 
quart of water and boil for one hour, skimming it from time to- time. 
Strain through a coarse colander. 

Keller's Malt Soup.— Take of wheat-flour 50.0 (about 2 ounces). To 
this add 11 ounces of milk. Soak the wheat-flour thoroughly, and rub it 
through a sieve or strainer. 

Put into a second dish 20 ounces of water, to which add 3 ounces of 
malt extract; dissolve the above at a temperature of about 120° F., and 
then add 10 cubic centimeters (about 2 1 / 2 drachms) of 11 per cent, potas- 
sium bicarbonate solution. Finally mix all of the above ingredients, and 
boil. 

This gives a food containing: — 

Albuminoids 2.0 per cent. 

Fat , 1.2 per cent. 

Carbohydrates 12.1 per cent. 

There are in this mixture: 

Vegetable proteids 0.9 per cent. 

The wheat-flour is necessary, as otherwise the malt soup would have 
a diarrhceal tendency. The alkali is added to neutralize the large amount 
of acid generated in sick children. Biedert emphasizes the importance of 
giving fat, rather than reducing its quantity, in poorly nourished children, 
and cites the assimilability of his cream-mixture or of breast-milk in under- 
fed children as proof of his assertions. The author ]jas used this malt 
soup most successfully in the treatment of athrepsia (marasmus) cases in 
which the children were simply starved. 

Mutton Soup. — Cut up fine 2 pounds of lean mutton, without fat or 
skin. Add 1 tablespoonful of barley, 1 quart of cold water, and a teaspoon- 
ful of salt. Let it boil slowly for two hours. If rice is used in place of 
barley, soak the rice in water over night, if it is to be boiled in the morning. 

Oyster Broth. — Cut into small pieces 1 pint of small oysters ; put them 
into 1 / 2 pint of cold water, and let them simmer gently for ten minutes 
over a slow fire. Skim, strain, and add salt. 

White Celery Soup. — Take 1 / 2 pint of strong beef -tea; add an equal 
quantity of boiled milk, slightly and evenly thickened with flour. Flavor 
with celery seeds or pieces of celery, which are to be strained out before 
serving. Salt to taste. 



DIETARY. 871 

Puddings and Desserts. 

Calf's-foot Jelly. — Thoroughly clean 2 feet of a calf, cut into pieces, 
and stew in 2 quarts of water until reduced to 1 quart ; when cold, take off 
the fat and separate the jelly from the sediment. Then put the jelly into 
a saucepan, with the shells and whites of 4 eggs well mixed together ; boil 
for a quarter of an hour, cover it, and let it stand for a short time, and 
strain while hot through a flannel bag into a mould. Flavor with lemon. 

Baked Apples. — Core and pare 2 tart apples; fill the core-holes with 
sugar; grate over the apples a little nutmeg; add a little water to baking- 
pan and put in oven and bake until the apples are soft. Serve with rich 
milk or cream. Sprinkle with icing sugar, if not sweet enough. 

Cornstarch Pudding. — Take 1 pint of milk, and mix with it 2 table- 
spoonfuls of cornstarch; flavor to taste; then boil the whole eight minutes; 
allow it to cool in a mould. 

Custard Pudding. — Break 1 egg into a teacup, and mix thoroughly 
with sugar to taste; then add milk to nearly fill the cup, mix again, and 
tie over the cup a small piece of linen ; place the cup in a shallow saucepan 
half -full of water and boil for ten minutes. 

If it is desired to make a light batter pudding, a teaspoonful of flour 
should be mixed in with the milk before tying up the cup. 

Infant's Gelatine Food. — About 1 teaspoonful of gelatine should be 
dissolved by boiling in 1 / 2 pint of water. Toward the end of the boiling 
1 gill of cows' milk and 1 teaspoonful of arrowroot (made into a paste with 
cold water) are to be stirred into the solution, and 1 to 2 tablespoonfuls of 
cream added just at the termination of the cooking. It is then to be mod- 
erately sweetened with white sugar, when it is ready for use. The whole 
preparation should occupy about fifteen minutes. 

Junket of Milk and Egg". — Beat 1 egg to a froth and sweeten with 2 
teaspoonfuls of white sugar. Add this to 1 / 2 pint of warm milk ; then 
add 1 teaspoonful of essence of pepsin (Faircbild) ; let it stand till it is 
curdled. The above is useful in typhoid and similar wasting diseases. 

Junket. — Add 1 teaspoonful of liquid rennin to 1 pint of milk. Mix 
and heat until the steam rises. Pour into cups and set aside to cool. 
Flavor with vanilla if desired. Or, to a bowl containing 8 ounces of cool 
milk, add 1 teaspoonful of pepsencia (Fairchild). Mix thoroughly. Place 
bowl in pan of boiling hot water, two minutes. Eemove, and let stand until 
jellied. 

Predigested Eggs. — Break a fresh egg. After thoroughly stirring add 
to it 2 grains of caroid powder and stir thoroughly. The yolk is at once 
changed into a limpid liquid and soon, though not so quickly, the albumin 
is completely dissolved. This is done at a temperature of TO to 80° F. 

Predigested Rice. — Take % pound of rice, add water, and boil until 
soft. Break grains by passing through a colander. Take, of bana-diatase, 



872 MISCELLANEOUS. 

8 grains/ and dissolve it in 1 ounce of water and add to the rice, which must 
be kept warm, but not hot. Let stand for two hours at a temperature of 
105° F. When rice is thoroughly softened, season with salt, sparingly. 
Add a little cream if desired. Serve hot or cold. 

Rice Pudding. — Boil a teacupf ul of rice, drain off the water ;. add a 
tablespoonful of cold butter. Mix with it a cupful of sugar, a quarter tea- 
spoonful of ground nutmeg, and a quarter teaspoonful of cinnamon. Beat 
up 4 eggs very light, whites and yolks separately; add them to the rice; 
stir in a quart of sweet milk gradually. Butter a pudding dish, turn in 
the mixture, and bake one hour in a moderate oven. 

If you have cold cooked rice, first soak it in the milk, and proceed 
as . above. 

Sago Pudding.— Same as above recipe, sago being substituted for rice. 

Soft Custard. — Take .of cornstarch 2 tablespoonf uls to 1 quart of milk ; 
mix the cornstarch with a small quantity of the milk, and flavor; beat up 
2 eggs. Heat the remainder of the milk to near boiling; then add the 
mixed cornstarch, the eggs, 4 tablespoonfuls of sugar, a little butter, and 
salt. Boil the custard two minutes, stirring briskly. 

Tapioca Cream. — Take 1 pint of milk, 2 tablespoonfuls of tapioca, 2 
tablespoon fuls of sugar, 1 saltspoonful of salt, and 2 eggs. Wash the 
tapioca. Add enough water to cover it, and let it stand in a warm place 
until the tapioca has absorbed the water. Then add the milk and cook in 
a double boiler, stirring often until the tapioca is clear and transparent. 
Beat the yolks of the eggs. Add the sugar and salt and the hot milk. 
Cook until it thickens. Eemove from the fire. Add the whites of the eggs, 
beaten stiff. When cold, add 1 teaspoonful of vanilla. ' 

Modified Cows' Milk. 

Humanized Milk. — A pint of milk is set aside until the cream rises, 
and this cream is skimmed off and kept. To the milk remaining is 
added enough rennet to curdle it. The whey is strained off the curd and 
added, with the previously separated cream, to a pint of fresh cows' milk. 
This is known as humanized milk. In some infants it will be well borne 
during the first three months, and to this .can be added farinaceous liquid 
for dilution if required. 

Pasteurized Milk. — This is really partially sterilized milk, and consists 
in heating to a temperature of 140° F. instead of 212° F., this heating to 
be continued from ten to twenty minutes. Pasteurized milk should only be 
used during the twenty-four hours following this process. A good apparatus 
for this purpose is Kilmer's pasteurizing apparatus. 

American Ferment Company. 



DIETARY. 873 

Predigested or Peptonized Milk. — This is milk in which the proteins 
are changed to peptones, or, in other words, digested, by the addition and 
action of pancreatic ferment. This process may be stopped when partially 
performed, giving a product of which the taste is not objectionable; or it 
may be carried on to complete peptonization, when the product has a very 
bitter, disagreeable taste. 

Method. — To partially peptonize milk, add to 1 pint of fresh cows' 
milk and 4 ounces of water, 5 grains of pancreatic extract and 15 grains of 
bicarbonate of soda. Allow this to stand at a temperature of 105° to 115° 
F. for five to twenty minutes, then bring to a boil to kill the ferment, or 
stand on ice to prevent its further action. If the milk is to be used at once, 
neither of these latter is necessary. 

To peptonize the milk completely, allow the process to continue for 
one to two hours. After this time the addition of acid produces no coagu- 
lation. 

In infant-feeding it is better to peptonize a modified than a whole 
milk. Peptonized milk is frequently very useful in feeding an infant with 
feeble digestive powers; but it is unwise to continue its use over too long 
a period, as then the infant's stomach, being called on to do no work, be- 
comes enfeebled from disuse, and gradually unable to perform its proper 
function. 

Whey. — By coagulating 1 pint of fresh (raw) milk by adding a tea- 
spoonful of essence of pepsin, and allowing this to stand, solid curd is 
formed, swimming in a liquid (whey). This has the following composition: 
Proteins, 0.86 per cent. ; fat, 0.32 per cent. ; sugar, 4.79 per cent. ; salts, 
0.65 per cent. ; water, 93.3 per cent. 

When such whey is added to milk for an infant under 6 weeks take, 
of whey, 2 parts; milk, 1 part. This can be increased until equal parts 
of milk and whey are used for a child several months old. 

Preparation of Sweet Whey. — Sweet whey is best made by the follow- 
ing method: For each pint of whey needed take 1 quart of raw milk 
or fat-free milk, heated to 37.7° C. (100° F.), and add 8 cubic centimeters 
(2 drachms) of the essence of pepsin or some of the preparations of liquid 
rennet. This will precipitate the casein in the form of a curd, which is 
then broken up with a fork; the fluid which remains is the whey. This 
is strained through two thicknesses of boiled cheese-cloth and one thick- 
ness of absorbent cotton and slowly cooled to a temperature of 10° C. (50° 
F.), and kept on ice until needed. If the whey is to be mixed with cream, 
it must first be heated to 65.5° C. (150° F.), in order to kill the rennet 
enzyme. Whey mixtures should not be heated above 68.3° C. (155° F.) 
if one wishes to keep safely under the coagulation-point of the lactalbumin. 
Add 1 teaspoonful of cane-sugar to each pint of liquid. 



874 MISCELLANEOUS. 

Miscellaneous. 

Milk Toast. — Take 1 cupful of milk, y 2 teaspoonful of cornstarch, V 2 
teaspoonful of butter, 2 slices of dry toast, 1 saltspoonful of salt. Scald 
the milk. Add the moistened cornstarch. Melt the butter in a saucepan; 
when hot and bubbling, pour in the hot milk slowly, beating all the time 
until smooth. Let it boil up once. Then add the salt. Toast 2 slices of 
bread. Pour the thickerjed milk over the slices. Let it stand a few 
minutes. Serve. 

Scraped Beef. — Scraped beef is prepared by scraping with a dull knife 
some raw or underdone lean beef. Add salt and serve on bread or biscuit. 

Scrambled "Eggs. — Take 2 eggs, a pinch of salt, 2 tablespoonfuls of 
milk, and a small piece of butter. Beat the eggs lightly, add the salt and 
milk. Put the butter into a saucepan; when melted and hot, add the eggs. 
Stir until of a soft, creamy consistency. Serve on buttered toast. 

Soft-boiled Eggs. — Drop 2 eggs into enough boiling water to cover 
them. Let them stand on the back of stove, where the water will keep hot, 
but not boil, for eight minutes. An egg to be properly cooked should never 
be boiled in boiling water, as the white hardens unevenly before the yolk is 
cooked. The yolk and white should be of jelly-like consistency. 



CHAPTER II. 
THE EXAMINATION OF THE GASTRIC CONTENTS IN CHILDREN. 1 

Chemical Examination. 2 

After the removed chyle is filtered it is ready for the following 
tests : — 

Hydrochloric Acid. — Free hydrochloric acid turns Congo-red a deep 
blue color; but as the presence of large quantities of lactic and other or- 
ganic acids gives the same reaction, and as the phloroglucin-vanillin ( Giinz- 
burg's reagent) does not respond to the organic acids, it is better not to 
depend upon the simpler Congo-red test. One or two drops of the filtered 
stomach-contents are placed on a white porcelain dish; the same amount 
of the reagent is added and thoroughly mixed with a glass rod; the dish 
is then gently warmed over the flame. The appearance of a bright cherry- 
red color on the edge of the residue indicates the presence of free hydro- 
chloric acid. 

To 10 cubic centimeters of the filtered chyle add 1 drop of 
phenolphthalein solution; to this add drop by drop from the burette a 
decinormal solution of potassium or sodium hydrate until after thoroughly 
stirring, a pink color persists ; now read carefully the number of cubic 
centimeters of the alkali solution used, multiply by 10 and 0.00365 (the 
decinormal factor of HC1) and the result is the percentage of HC1. If suf- 
ficient material is at hand, the estimation should be repeated to avoid pos- 
sible error. 

Lactic Acid (TJffelmann's Test). — One drop of the solution of ferric 
chloride is added to 20 cubic centimeters of the 1 / 2 per cent, carbolic acid 
solution; this is diluted till a transparent amethyst blue color is obtained. 
A few drops of the fluid to be tested added to a few cubic centimeters of 
this solution in a test-tube, change the amethyst-blue to a canary-yellow if 
lactic acid be present. On account of the presence of various other substances 
this test is sometimes not distinctive when the untreated chyle is used. A 
more certain procedure is to acid to 10 cubic centimeters of the filtered 
chyle in a test-tube 110 cubic centimeters of ether; shake thoroughly; 



1 With a soft flexible catheter I syphon the gastric contents about two hours 
after feeding; if the stomach is irritable and children vomit, then the vomited 
material is used. 

2 1 am indebted to Boas' valuable book on "Diseases of the Stomach" for many 
points in the chemical examination and methods used. 

(875) 



876 MISCELLANEOUS. 

allow the ether to separate; decant the ether into a clean test-tube; place 
the test-tube containing the ether in a glass of warm water till the ether 
has evaporated; add 5 to 10 cubic centimeters of distilled water to the 
residue., and test as above for lactic acid. 

Propeptone. — To 5 cubic centimeters of chyle, add 5 cubic centimeters 
of saturated solution of sodium chloride and 2 drops of acetic acid. A 
cloudiness or precipitate indicates propeptone, especially if the precipitate- 
disappears on heating and returns on cooling. 

Peptone. — Filter out any propeptone from the last named; add an 
excess of sodium hydrate solution ; mix thoroughly and add 1 or 2 drops of 
a weak solution of copper sulphate ( 1 / 2 per cent.) ; the appearance of a 
violet-red or old-rose color indicates peptone. This is the so-called biuret 
reaction which most peptones and albumoses give. 

Pepsin. — For this test we require uniform, small pieces of coagulated 
albumin; these should be little circular slices of hard boiled white of egg, 
1 centimeter in diameter and 1 millimeter in thickness, which may be 
preserved in glycerine. One of these discs is placed in a test-tube 
containing 5 cubic centimeters of filtered chyle and kept at a temperature 
of 99° F. ; if it has been already shown that hydrochloric acid is absent, 
1 drop or 2 of dilute hydrochloric must be added. The tube is observed 
every twenty to thirty minutes to note the progress of digestion and the 
time required for complete disappearance of the egg albumin. 

Rennet. — Add a few drops of chyle to 5 or 10 cubic centimeters of 
milk and place tube in water at a temperature of 99° F. 

Motility. — The motility of the stomach may be tested in various ways; 
probably the salol-test, although open to many objections, is the most used. 

This test finds the foundation for its use in the fact that salol is not 
absorbed until it reaches the alkaline secretions of the intestine, by which 
it is decomposed. The test is untrustworthy when the stomach secretion 
is alkaline. The time between ingestion and the appearance of salicyluric 
acid in the urine is noted by examining the urine at intervals of one-half 
and one hour after tak'ng 15 grains of salol (immediately after meal). 
If salicyluric acid be present in the urine, the addition of a few drops of 
a solution of ferric chloride gives a violet co^r. If the appearance of the 
test be delayed longer than an hour or an hour and fifteen minutes, the 
motility is usually considered below normal. 



CHAPTER III. 

URINE. 

Method of Collecting Urine. 

In collecting urine from an infant we can apply a pad of sterile ab- 
sorbent cotton or a flat sterile sponge to the vulva. After urination the 
urine absorbed can be filtered into a bottle. If the urine thus secured is 
rot sufficient for examination, the method can be repeated several times. 
In boys the smallest size rubber ice-bag can be drawn over the genitals and 
a specimen secured in this manner. 

If for any reason this method cannot be carried out, and it is vital 
that the examination be made, then an infant's size catheter may be used 
to draw off the urine. 

The First Urine. 

The first urine drawn by catheter is acid, almost always clear and but 
slightly colored. During the first four or five days it is more or less cloudy 
from the presence of epithelial cells from the urinary passage, and uric 
acid salts. The specific gravity averages about 1012. The sediment always 
contains normal epithelial cells, various forms of uric acid crystals, and 
now arid then hyaline casts. The amount of urine is small (Morse). This 
is due in part only to the insufficient supply of milk, as the amount is also 
small in bottle-fed infants. It increases rather rapidly about the fourth 
day, 20 to 50 cubic centimeters being passed in the first three days, and 
about 100 cubic centimeters on the fourth day. In the second week it 
averages between 200 and 300 cubic centimeters. 

The proportion of water eliminated in the urine to that taken in the 
food is greater after the fourth day, averaging 22 per cent, to 25 per cent, 
before, and 50 per cent, to 60 per cent, after. 

The urine of breast-fed babies almost never contains indican, that of 
the artificially fed baby usually but slight traces. Urobilin is never pres- 
ent in that of the breast-fed, seldom in that of the artificially fed. It does 
not contain albumin, and sugar is absent with the ordinary reagents. The 
sediment is slight, and consists entirely of cells. One-third to one-half 
gram of urea per kilo of body weight is said to be passed in twenty-four 
hours. Figures are of but little use, however, as the amount of urea varies 
with the character of the food. It is pretty certain, nevertheless, that 
from 40 to 50 per cent, of the nitrogen ingested appears in the urine. 
The amount of urine is relatively large. It varies between 200 and 500 

(87?) 



878 MISCELLANEOUS. 

cubic centimeters from one to six months, and between 250 and 600 cubic 
centimeters up to 2 years. 

The urine of the new-born is rich in sodium chloride, which salt 
diminishes with age. During the first and second months of life it is in 
the same proportion as in adults. From the third to the fifth year, com- 
puted by kilogram weight, the amount is 0.57 gram; at 11 years, 0.44 
gram, and at 16 years, 0.18 gram. 

Phosphoric acid is seldom found, but when met with it is always in 
very minute quantity. 

Uric acid is present in the earliest urine, and the quantity regularly 
increases up to the third day, when it rapidly diminishes. 

On examining the kidneys of a new-born, the papillae will be found 
filled with a reddish substance which obstructs the urinary ducts; this, 
as is well known, is nothing more than uric acid infarction and has no 
pathological significance. 

Parrot and Eobin found urate of soda, sulphate of calcium, mag- 
nesium, potassium, benzoic acid, allantoidin, and mucin, and Cruse denies 
the presence of sugar, oxalate of calcium, or hippuric acid. Creatinine 
and indican are not found in the urine of the new-born or wet-nursed. 
Xanthine is relatively abundant in cases of nephritis. 

In infantile atrophy, as may be presumed, the quantity of urine is 
far below the normal; it is yellow, acid reaction, often contains organic 
deposits, sugar, albumin and an excess of urea and phosphates. 

In icterus neonatorum the urine is pale-yellow, and contains urates, 
epithelial cells, and yellow masses of pigment. 

The urine of infants with scleroderma is reddish, acid with uratic 
deposits, and slight excess of urea. 

Albumin. 

The presence of albumin is always of importance, although not always 
due to an inflammatory process of the kidneys. It is often the sign of a 
simple congestion in athrepsia, cholera infantum, general or intestinal 
tuberculosis, intestinal catarrh, typhoid and scarlet fever. 

"A small amount of albumin in the form of nucleo-albumin is almost 
constantly present in the urine during the first four days of life. It often 
persists for two weeks, and not infrequently for two months. There is 
much difference of opinion as to the cause of this albuminuria. It has 
been attributed to the changes in the circulation at birth, to hyperemia 
resulting from the changes in the metabolism after birth, to renal disease 
in the mother, and to irritation from uric acid. It is doubtful if any of 
these explanations are correct. The latest investigations show that albu- 
minuria is no more common in the children of women suffering from 
nephritis or eclampsia than in others. If uric acid is the cause, its action 



URINE. 379 

is probably as a chemic rather than as a mechanic irritant. Many observ- 
ers regard this albuminuria as physiologic. It is hardly safe to consider 
it so, however, until more is known about metabolism, the changes due to 
nourishment, and disturbances of nutrition in the new-born. Whatever 
the cause, it is certainly not a serious condition, and ought not to be looked 
upon as the forerunner of chronic nephritis in later life." 

In older children the presence of albumin in the urine is always 
pathological, except when it is the physiological result of the administra- 
tion of certain drugs (tincture of iodine, etc.). 

A slight amount of albumin may be found in nephritic colic due. to 
the stimulus which the uric acid exerts upon the renal parenchyma. At 
other times, when present, there is an actual inflammation of the kidneys, 
as in scarlatina and diphtheria; there may be an amyloid degeneration 
without its being possible to discover any albumin in the urine. 

Sometimes children will be found pale, the urine perhaps abundant 
or diminished in quantity; it will contain albumin, a few hyaline casts, 
uric acid and epithelium, yet they will have good appetite, will play and 
appear otherwise quite well. Others become languid, lose their appetite, 
complain of headaches, painful micturition, and will pass a turbid and 
sedimentous urine. In these cases albumin soon appears. 

The more severe cases suffer from anuria ; partial oedema will occur 
in the eyelids, on the dorsum of the foot, etc. The next day the amount 
of urine will have been 50 to 100 grams in' twenty-four hours. This will 
increase, perhaps, never to return to the normal. 

The color of the urine in Bright's disease will be variable, according 
to the amount of blood which it may contain, of acid reaction, and average 
specific gravity of 1010 to 1015. Under the microscope we find red and 
white corpuscles, haematin, renal epithelium, hyaline or granular casts, 
uric acid crystals, fat globules, and detritus. 

Chronic nephritis may be the result of an acute affection complicating 
scarlet fever. In these cases children suffer but little and seldom show 
more than a few cedematous spots. 

These forms of kidney involvement are rather rare, and cases which 
have been diagnosed as such have, on autopsy, proven to have been cases 
of amyloid degeneration due to syphilis, malaria, rachitis, struma, or 
tuberculosis. 

In the mild forms of diphtheria the urine suffers no change what- 
ever, but in the general infection, even in the early stages, albuminuria is 
found, which is a fairly positive evidence of systemic infection. If 
the urine diminishes in quantity and blood corpuscles are found under 
the microscope we may feel sure that the diphtheritic process has invaded 
the kidney, or else that a nephritis complicates the diphtheria. 

"In rachitis, albuminuria is comparatively rare; the quantity does not 



880 



MISCELLANEOUS. 



change materially, but the calcium salts have been found in marked dimin- 
ution. Marchand and Lehman have discovered lactic acid present. The 
phosphates and chlorides are in very small quantities. The urine of leu- 
ksemic patients at times contains albumin and many lymph corpuscles as 
well as hyaline casts. The uric acid and hypoxanthine are in greater 
quantity. 

"Diabetes mellitus has been met with at a very tender age. 
"In a case of pseudo-hypertrophic paralysis Dennen reports marked 
glycosuria. 

"Hemoglobinuria is found in "Winckel's disease, and the same as in 
adults, in malaria, syphilis, and as a result of exposure to cold. 

"Hematuria and pyuria have no 
special significance beyond that which 
they have in adults. 

"Uric acid is in excess during the first 
week and is a physiological phenomenon; 
later on, deposits of urates and uric acid 
appear in the course of serious diseases of 
the digestive apparatus. Under other 
circumstances, the oxidation of nitrogen- 
ous substances being diminished (by dis- 
eases of the" respiratory or central nervous 
system), deposits of oxalate of calcium 
occur. 

"Infarcts of uric acid may be found 
even up to the seventh or eighth week. 
Children will strain, make repeated ef- 
forts and cry out during urination; the 
diapers will be found stained with a 
darker urine than usual; the edges of the 
wet surface will be seen reddened by a 
yellowish-pink sandy deposit. A careful 
analysis of this urine regularly shows an 
excess of uric acid, many epithelial cells, 
a few pus corpuscles, and mucus and traces of albumin. Quite frequently 
the urine is so acid as to produce such pronounced evidences of pain on the 
part of the infant as are met with in the nephritic colic of adults. 

"When tubercle bacilli are present in urinary sediment, the diagnosis of 
tuberculosis of the kidneys, ureters, or bladder may be positively made. 
Care should be exercised not to confound the tubercle bacillus with the 
smegma bacillus, which may often be present in the same specimen of 
urine and which stains like the former, though it decolorizes differently. 
1 It can be procured at Eimer & Amend, chemists' supplies, New York City. 




Fig. 298. — Urino-Pyknometer, 1 
for estimating the specific gravity 
of small volumes of urine. 



URINE. 



'881 



"The epithelium found in urinary sediments is often of great import- 
ance in determining in what part of the genito-urinary tract the lesion 
exists, and a knowledge of the histology of these organs will sometimes 
prove invaluable. 

"The presence of echinococcus, filaria, etc., determines the exact nature 
in those diseases. 

"Dysuria is not always a manifestation of renal or vesical disease, since 
a high fever may at times originate it. In such cases children complain or 
cry out on attempting to urinate. 

"This symptom belongs as well to affections of the external genitals 
such as phimosis, urethritis, congenital anomalies of the urethra, those of 
the labia minora in females, etc." 

Specific Gravity. — The specific gravity of the urine is best taken with 
a hydrometer. If the urine is very scanty an instrument called the urino- 
pyknometer, devised by Dr. Saxe, should be used. It has the advantage of 
giving the specific gravity when only 1 drachm or 3 cubic centimeters can 
be procured. 

Test for Albumin. 

Place in a test-tube about half a teaspoonful of pure water, in which 
dissolve one of the potassio-mercuric iodide tablets and one of the citric 
acid tablets. To this solution gradually add, drop by drop, the urine. If 
a gelatinous precipitate occurs, it may consist of albumin, an alkaloid 
such as quinine, or peptone. To determine which of these three sub- 
stances was originally present in the urine, heat the contents of the tube 
to the boiling point and note if the precipitate is redissolved. If such be 
the case, the precipitation was due to peptone and not albumin, as the 
latter would be coagulated and would not be dissolved. If the precipitate 
consists of a compound of the reagent with an alkaloid, it will be dis- 
solved completely upon the addition of alcohol, a result which would not 
occur if the precipitate consisted of albumin. The potassio-mercuric iodide 
test is exceedingly sensitive, and whenever the results are negative, no 
precipitate occurring upon the addition of the urine, it is positive evidence 
of the absence not only of albumin, but of peptone and alkaloids as well. 
It is only in such cases where a precipitate occurs that it becomes necessary 
to apply alcohol and heat tests to determine the character of the precipi- 
tate. 

Directions for Use. — In testing urine for albumin with nitric acid, fill 
the large tube of the horismascope two-thirds full of the urine, which must 
be made perfectly clear and transparent, if necessary by filtration. Then 
pour into the funnel tube 25 or 30 minims of nitric acid, which will pass 
down through the capillary tube and form a layer underlying the urine. 

56 



882 



MISCELLANEOUS. 



If albumin is present, a distinct white zone will presently appear at the 
point of contact, sharply denned against the black background, the amount 
of albumin being indicated by the density of the opaque ring. Sometimes 
air will remain in the capillary tube of the instrument, preventing the acid 
from running down the tube. It is always best to see that the tube is free 
from air before pouring in the ac^d. If air is present, it can generally be 
driven out by merely tilting the instrument or it may be driven down the 
tube by placing the thumb or middle finger on top of the funnel so as to 
cover it completely and pressing quickly and forcibly so as to cause a few 
bubbles of air to pass through the urine. 

In the use of the horismascope in 
applying the nitric-acid test for albu- 
min, these advantages are secured: 

1. The acid when it comes in con- 
tact with the urine is of full strength, 
rendering the test much more delicate 
than as ordinarily applied. 

2. The reaction is not liable to be 
obscured by separation of uric acid or 
acid urates, such separation not taking 
place in the horismascope until after 
a considerable interval. 

3. The black and white back- 
grounds of the instrument render much 
more distinct the effects produced by 
the reagent. 

4. No especial skill is required on 
the part- of the operator. 

The faintest visible trace of al- 
bumin as shown by the nitric acid 
test may be stated to be 1 / 60 per cent. 
One-fourth of 1 per cent, is just suffi- 
cient to make the albumin layer opaque when viewed from above. If larger 
amounts are present the percentage may be approximately estimated by 
diluting the urine until the opacity is reduced to that corresponding with 
0.25 per cent. 

There are many other tests which can be advantageously made by 
introducing the reagent from beneath, allowing it thus to form a distinct 
stratum underlying the fluid to be tested. 

In testing a specimen of urine it is always best to first determine its 
reaction. For this purpose red and blue litmus paper should always be at 
hand. A small piece of each kind of paper should be added to the specimen 
and the result be observed. If the- urine is alkaline the red litmus paper 




Fig. 299. —The Horismascope or Albutno- 
scope. A new instrument for determining the 
presence and amount of albumin in the urine. 
No liability of the acid mixing with the urine. 
The slightest visible trace of albumin can be in- 
stantly detected against the dark background. 
Color reactions due to urinary and biliary pig- 
ments are clearly shown against the white 
background. 



URINE. 883 

will turn blue, and if it is acid the blue litmus paper will turn red. It is 
very important that when testing for sugar the urine should be slightly 
alkaline", and when testing for albumin it should be slightly acid. In order 
to render the specimen slightly alkaline or slightly acid according to the 
test that is to be applied, sodium carbonate tablets and citric acid tablets 
should be used. 

Robert's Albumin Test. 

IJ Sat. sol. magnes. sulph. (c. p.) 5 ounces 

Nitric acid (c. p.) 1 ounce 

This test is a cold one, viz. : put about 1 cubic centimeter of solution 
into medium-sized test-tube — incline on a steady rest on an angle of 45 
degrees. With a slender pipette allow the filtered urine to be tested — to 
flow very slowly down the side of the tube. It will float above test solution. 
Use about 1 cubic centimeter of urine. Examine in front of the window 
by daylight, with aid of black background. A sharp clear-cut, white line 
will appear at contact line if albumin is present. A wide band of white 
is not always indicative of albumin, neither is a narrow zone above in the 
urine, which may be due to mucus. The sharp, clear-cut zone is distinctive. 

A New Test for Albumin. 1 — This new and simple test is based upon the 
following facts : — 

1. Albumin is coagulated by carbolic acid. 

2. Equal volumes of non-albuminous urine and a mixture, composed 
of equal parts of carbolic acid and glycerine, form an emulsion which clears 
up entirely upon agitation, leaving a perfectly transparent and highly re- 
fractive liquid. 

3. Equal volumes of albuminous urine and the above mentioned carbol- 
glycerine solution, when mixed together, produce a white turbidity, which 
remains, in spite of agitation, and does not precipitate on standing nor 
redissolve. 

The test is very sensitive, distinctly showing the presence of 0.1 per 
cent, of albumin in the urine, the degree of turbidity being proportionate 
to the percentage of albumin contained in the urine. 

Test. — Two cubic centimeters of carbol-glycerine solution are poured 
into a small test-tube, and 2 cubic centimeters of the filtered urine are 
added. Mix thoroughly with a glass rod, or agitate. If a clear, transparent 
liquid results, there is no albumin present; but if the slightest turbidity is 
noticeable the urine is albuminous. 

The Diazo Reaction in Urine. — The diazo test was suggested by 
Ehrlich, in 1882, as a valuable diagnostic measure in typhoid fever, al- 
though he admitted the occurrence of this reaction in a few other con- 
ditions shortlv to be considered. 



Fuhs, Medical Record, March 8, 1902. 



884 MISCELLANEOUS. 

The diazo reaction depends upon the fact that if sulphanilic acid 
(amidosulphobenzol) be acted upon by HNO, diazosulphobenzol is formed, 
which unites with certain aromatic substances occasionally present in the 
urine to form aniline colors. 

Friedenwald has recently reviewed the literature of this reaction, and 
showed that many of the contradictory results obtained by some observers 
are due to failure in carrying out Ehrlich's methods in performing the 
test, which, is best accomplished as follows : — 

To obtain diazosulphobenzol in a perfectly fresh condition sulphanilic 
acid is kept in solution with hydrochloric acid ; to this sodium nitrate is 
added, whereupon HNO is liberated and diazosulphobenzol is formed. 

Process. — Two solutions are prepared, as follows: — 

1. Two grams of sulphanilic acid, 50 cubic centimeters of hydrochloric 
acid, 1000 cubic centimeters of distilled water. 

2. A 0.5 per cent, solution of sodium nitrite. 

In performing the test, 50 parts of No. 1 and 1 part of No. 2 are 
mixed, and equal parts of this mixture and of) the urine in a test-tube are 
rendered strongly alkaline with ammonia. If the reaction be positive the 
solution assumes a carmine-red color, which on shaking must also appear 
on the foam. Upon standing for twenty-four hours a greenish precipitate 
is formed. 

The test must not be considered positive unless a distinct red colora- 
tion extends to and includes the foam on shaking. ■ 

Indican". 

To two inches of urine in a test-tube add ten drops of strong hydro- 
chloric acid and two drops of fuming nitric acid, allow to cool ; add one-half 
inch of chloroform and shake up thoroughly. If indican is present, the 
chloroform, when it again sinks to the bottom of the test-tube, will be 
tinged either blue or red. 

Fallacy. — Albumin interferes with the test — if present remove same 
by adding acetic acid, boiling, and filtering off the coagulated protein. 

Jaffe's test consists in mixing 10 cubic centimeters of strong hydro- 
chloric acid with an equal volume of urine in a test-tube, and, while shak- 
ing, add drop, by drop a perfectly fresh, saturated solution of chloride of 
lime, or chlorine water, until the deepest obtainable blue color is reached. 
The mixture may next be titrated with chloroform, which readily takes up 
the indican and holds it in solution, and the quantity present may be 
approximately estimated according to the depth of the color. If the urine 
contains albumin it should be removed before applying this test, otherwise 
the clue color, often arising from the mixture of hydrochloric acid and 
albumin after standing, may prove misleading. 



TEST FOR SUGAR IN URINE. 885 



Test for Sugar (Glucose) in Urine. 

The best test for sugar is furnished by the indigo and sodium car- 
bonate tablets. This test is applied by first placing in a test-tube about 
half a teaspoonful of water, one of the indigo and sodium carbonate tab- 
lets, and one of the sodium carbonate tablets. Heat the contents of the 
tube gently until solution is effected, and then add 1 drop of the urine to 
be tested, keeping the fluid at the boiling point without allowing it to boil. 
If no effect is produced add a second drop of the urine and heat as before. 
If no change of color results add another drop of the specimen, and so on 
until at ltast five drops have been added. If any notable amount of sugar 
is present, one or at least two drops will suffice to bring about the reaction. 
The fluid will change from pure blue to amethyst, then to purple and red, 
finally fading to a pale yellow. If the quantity of sugar is very small, the 
color will change only to a purple or red, and in nearly every case five drops 
of normal urine will produce this change. 

If one drop of the urine produces a strong reaction, dilute the urine 
to one-half, one-quarter, one-eighth, etc., in succession until a single drop 
ceases to produce a visible change, and estimate roughly in this manner 
the quantity of sugar present. While observing the various changes of 
color which the liquid undergoes, if sugar is present, any agitation of the 
solution should be carefully avoided. The reason for this precaution is 
readily explained by the fact that the original blue color of the solution 
"may be restored by simply shaking -the liquid. This remarkable effect is 
not due to cooling, but to the oxidizing influence of the air. 

In regard to the comparative value of tests for sugar, it may be said 
that the copper test is the least trustworthy. Among the normal constit- 
uents of the urine, uric acid is capable of reducing copper compounds, and 
numerous substances which may accidentally be present have a similar 
action. The indigo test is capable of detecting a smaller quantity of sugar 
in the urine than any other reagent. One drop of a solution of glucose, 
containing a half grain to the fluidounce, shows a distinct reaction. 

Nylander's Test. — Solution is composed of 2.0 bismuth sub nitrate, 4.0 
Eochelle salt, and 100.0 of an 8 per cent, solution of sodium hydrate. One 
part of this solution added to 9 parts by volume of the urine and the mix- 
ture boiled for a time. The reaction begins as a grayish black coloration 
of the whole mixture, which soon becomes a deep black. 

This test is a delicate one, and it reveals sugar in ordinary urines in 
amounts of 0.05 per cent., in concentrated urines only in amounts of 0.1 
per cent, upward. A faint reaction may be produced even in non-saccharine 
urines, especially when drugs such as rhubarb and senna, antipyrin, salicylic 
acid, camphor, chloroform, chloral hydrate, saccharine, and turpentine have 



886 MISCELLANEOUS. 

been ingested. All of these substances may reduce cupric and bismuth 
oxide to a certain degree. 

Fermentation Test. — With the aid of a saccharometer we have a con- 
venient method of estimating the quantity! of sugar in the urine. A piece 
of yeast-cake about the size of a pea is added to a test-tube o£ urine, and 
allowed to stand at a temperature of 90° F. If sugar is present, yeast 
transforms it into alcohol and carbon dioxide, by fermentation. While this 
test is reliable, it is not a very delicate one. 

Blood. 

Heller's Test. — Uriue is rendered strongly alkaline with potassium 
hydrate and boiled. On cooling the blood coloring matter is carried down 
with the precipitated earthy phosphates and tinges the latter (which other- 
wise appears as white flocculi) brownish or garnet red. 

Fallacies. — Earthy phosphates may be deficient in the urine and no 
deposit result. To obviate this add two drops of calcium chloride solution. 

Certain drugs, as rhubarb, senna, santonin, give a similar reaction. 

Guaiacum Test. — To one inch of urine in a test-tube, add one drop of 
tincture of guaiacum : the resin forms a white precipitate. Pour on to the 
surface one inch of ozonic ether. If blood be present, it and the ozone 
ether together oxidize the guaiacum, and a blue color appears at the junc- 
tion of the fluids. 

Fallacies. — (1) Pus gives a similar color, but it is more green than 
blue, and appears more slowly. 

(2) Iodides in urine give a similar blue color, but it appears more 
slowly than with blood. 

Pus. 

The deposit is opaque and white; in small quantities it may be mis- 
taken for mucus ; in larger quantities for phosphates or for colorless urates : 
urates disappear on warming — pus remains — phosphates increase with heat, 
but clear up with acetic acid. 

Liquor Potassae Test. — To one inch of the suspected deposit in a test- 
tube add a few drops of liquor potassse; pour the mixture from one test- 
tube into another. Pus will have partially dissolved, and become ropy and 
gelatinous. 

Fallacy. — The test will not detect small quantities of pus. 

Ozonic Ether Test. — To one inch of the deposit in a test-tube add a 
few drops of ozonic ether; on gently shaking, numbers of small bubbles of 
liberated oxygen will be seen rising through the fluid. 

Fallacy. — Blood also causes bubbling with ozonic ether. 



DIACETIC OR ACETOACETIC ACID TEST. 887 

DlACETIO OR ACETOACETIC ACID TEST. 

Gerhardt's Iron Chloride Reaction. — To one inch of urine in a test- 
tube add liquor ferri perichlor (B. P.) drop by drop; a white precipitate 
of iron phosphate forms first, but almost immediately if acetoacetic acid be 
present, the liquid becomes deep purple-red, the color being discharged 
again on warming. 

Acetone Test. 

Legal's Test. — A few drops of a fresh solution of sodium nitroprusside 
are added to the urine and a saturated sodium hydrate solution until a 
distinct alkaline reaction is produced. After the purple color produced by 
their addition has been succeeded by a pale yellow, carefully add a few 
drops of a saturated acetic acid. If a bright purple or carmine color appears, 
the presence of acetone is proven. 

Bile Pigments. 

Gmelin's Test. — Upon a white porcelain slab put one drop of the urine 
and close to it a drop of fuming nitric acid. At their point of coalescence 
a play of colors — yellow, green, red, and blue — will occur if bile pigments 
are present. 

Chlorides. 

The tests for chlorides are dependent upon the formation of silver 
chloride on adding a solution of silver nitrate to a urine previously acidu- 
lated with strong nitric acid. This is to prevent the formation of silver 
phosphate. A ten per cent, solution of the silver salt is used, and an exactly 
similar test is to be made on normal urine as a control. Any reduction in 
an amount sufficient to be of diagnostic value can be made out by the dif- 
ference in bulk of the precipitate of silver chloride formed in the two test- 
tubes. Albumin must be removed before applying the test. 



CHAPTEE IV. 
BACTERIOLOGICAL MEMORANDA. 1 

Demonstration of Tubercle Bacilli in Sputum. 

With a forceps pick out a thick, purulent portion of the sputum. 
Make a thin spread between a slide and a cover-glass. Allow this to dry 
thoroughly in the air or it can be dried by holding it several inches above 
a Bunsen burner. Stain with several drops of ZiehTs solution and heat 
it over a Bunsen burner: — 

Ziehl's solution : — 

I£ Fuchsin 1 gram 

Alcohol 10 grams 

Carbolic acid 5 grams 

Water -. 100 grams 

After heating wash the cover-glass in water, and lastly add several 
drops of Gabbet-Ernst solution: — 

I£ Methylene blue 2 grams 

Diluted sulphuric acid (25 per cent.) 100 grams 

Einse this solution off the cover-glass, dry between filter paper, and 
mount with Canada balsam. 

Under the immersion lens the tubercle bacilli will be stained red, and 
all other bacteria will have the blue background. 

Aqueous Solutions. — Aqueous solutions of methyl violet, gentian vio- 
let, fuchsin, and the other aniline dyes are prepared by adding 1 cubic cen- 
timeter of the saturated alcoholic solutions of the desired dye to 20 cubic 
centimeters of distilled water. This will impart a decided color to the 
liquid so that a pipette full will be barely transparent. 

The true aqueous solutions are made by dissolving the dyes in water, 
but these are weak and not so effective as those prepared from the alcoholic 
solutions. These solutions deteriorate in a short time. The carbol-fuchsin 
and alkaline methylene blue will keep a little longer, but they require to 
be filtered occasionally. 



1 The reader is referred to works on bacteriology ( such as Lenhartz-Brooks ) 
for blood examinations in malaria, anaemia, leukaemia, and for the Widal reaction 
of the blood in typhoid fever. 

(888) 



BACTERIOLOGICAL MEMORANDA. 889 



Gonococcus. 

With a platinum loop pick out a thick purulent portion of the dis- 
charge. Make a thin spread between two slides. Dry in the air or over a 
iBimsen burner. 

Cover preparation with aniline gentian violet solution (preferably 
fresh) for five minutes, pour off excess of stain and cover with Gram's solu- 
tion for two to five minutes. 

Gram's Solution. 

B Iodine 1 gram 

Potassium iodide 2 grams 

Distilled water 100 grams 

Decolorized with 95 per cent, alcohol until no further traces of the 
stain can be washed out of the preparation. Wash in water and counter- 
stain with an aqueous contrast stain, preferably Bismarck brown. Wash in 
water, dry and examine under oil immersion lens. The gonococci will take 
the counter stain. 

Diplococcus Pneumonia. 

With a platinum loop pick out a thick portion of the sputum. Make 
a thin spread between two cover-glasses. Immerse in a watch-glass of 
aniline gentian violet for ten minutes. Pass through water, and place in 
Gram's iodine solution for five minutes. Wash in alcohol until no further 
color comes away. Place on edge to dry. Mount in Canada balsam. 

Klebs-Loeffler Bacillus. 

Bacteriological method of diagnosis is given in detail in chapter on 
"Diphtheria." Bacillus stains well with Loefrler's alkaline; methylene blue. 

Streptococcus. 

Usually found in purulent ear, eye, or nasal discharges, sometimes in 
vaginitis. 

With a platinum loop pick out a thick portion of the discharge. Make 
a thin spread between two slides. Dry in the air or over a Bunsen burner. 
Stain with methylene blue or fuchsin solution. Mount in Canada balsam. 

Meningococcus. 

Lumbar puncture fluid in cerebrospinal meningitis should be spread 
between two cover-glasses and dried over a Bunsen burner. Stain and 
mount as for gonococcus. 



CHAPTEE V. 

ANESTHETICS IN CHILDEEN. 

Nitrous Oxide and Ether. 

The ideal anesthetic for children is a combination of nitrons oxide 
and ether. Whenever it is possible one skilled in its administration should 
be employed. The responsibility of attending to a major or minor opera- 
tion is so great that nnless one skilled in the administration of an anaes- 
thetic is employed there may be serions after-effects. To properly guard 
the heart and respiration requires experience, and no snrgeon should un- 
dertake to do both, excepting in extreme emergencies. 




Fig. 300. —Gas and Ether Inhaler. 



Walter K., 5 years old, was given a mixture of nitrous oxide and ether by Dr. 
Culler. The child was anaesthetized without a struggle. I removed the adenoids 
and hypertrophied tonsils. The child showed no evidence of shock. There was 
slight nausea. No other evidence of gastric disturbance. There were no after- 
effects. 

Chloroform. 

Chloroform vapor is decomposed into chlorine and hydrochloric acid 
by the presence of the common gas flame, and may thus give rise to irri- 
tating effects upon the respiratory organs. 
(890) 



ANESTHETICS. 891 

When employed it should be administered by the drop method. By 
this method, combined with fresh air, the danger is minimized. The statis- 
tics of Dr. George Gould, of Philadelphia, and the Lancet Commissioner, 
prove that chloroform anaesthesia causes more deaths than ether as an 
anaesthetic. 

Ethyl Chloride. 

This is an excellent anaesthetic and can be administered as a spray on 
a chloroform mask. I have frequently used it in my hospital service to 
remove adenoids, tonsils, and for a circumcision. Ethyl chloride is a rapid 
and safe anaesthetic. 

Local Anwstliesia. — Ethyl chloride, as a spray, until the part is frozen, 
is sufficient to open an abscess, for a lumbar puncture, or even an empyema, 
in a sensitive child or where general anaesthesia is contraindicated. 

The inhalation of ethyl chloride is also of great advantage where 
a short ancesthesia is required, as, for instance, when a paracentesis of the 
ear is to be made. An advantage of ethyl chloride over ether or chloroform 
is that it is not followed by nausea or vomiting. 

Ether. 

Sulphuric ether, used alone as an anaesthetic in children, may be 
considered. It requires a much longer time to produce its effect, 
although it has no depressing effect upon the heart. Statistics show that 
in 300,175 administrations of ether there were 18 deaths. Out of 638,461 
of chloroform, there were 160 deaths, showing the following ratio : — 

Chloroform mortality 1 to 3,749 

Ether mortality 1 to 16,675 

We therefore see that ether is by far the safer anaesthetic. Weir states 
that "ether narcosis is safer, even though the kidneys are slightly affected." 
Ether is frequently combined with oxygen, and, as previously stated, with 
laughing gas, and forms in the latter combination the safest anaesthetic for 
children. 

Regarding the Effect of Ether in Affections of the Air Passages. — 
Affections of the air passages following ether narcosis are usually the result 
of aspiration of infected mouth contents. Ether causes a slight increase of 
mucous secretion. It has no irritant action on the tracheal or bronchial 
mucous membrane. When bronchitis or pneumonia exists, greater care 
must be taken owing to the increased secretion produced by the ether, as 
stated above. When nitrous oxide is given we avoid the irritant effect just 
described. 

In adenoid operations, give nitrous oxide until cyanosis is seen, then 
give ether; the change relieves cyanosis at once. 



892 MISCELLANEOUS. 

Lymphatic Enlargement in Children. — Most deaths occur in children 
in which the lymphatic condition exists — the so-called lymphatic diathesis. 

The Children's Clinic at Graz, during the last twenty years, shows 
that records of fatalities with chloroform always revealed the lymphatic 
hyperplasia, which is the principal feature of the so-called constitutio lym- 
phatica. (Eead chapter on "Status Lymphaticus.") 

Ewing believes the above conditions prevail in America. Lartigan's 
report of the Eoosevelt Hospital shows that death came after ether as well 
as after chloroform, in children affected by the lymphatic constitution. 

The presence of universal enlargement of the lymph nodes without 
direct inflammatory cause, hypertrophied tonsils, adenoid hyperplasia, 
tendencies to anaemia, weakness of pulse, irregular heart's action, along 
with insufficient development of the heart and large blood-vessels, show 
that the lymphatic condition exists. 

Local or Intea-spinal Anesthesia. 1 

Corning, of New York, about twenty years ago found that anaesthesia 
could be produced in the lower part of the body by injecting cocaine in the 
lumbar region of the spine. The patient is placed in a sitting position 
well bent forward, and firmly held during the injection. The skin should 
be cleaned in the usual antiseptic way, followed by an ethyl chloride spray. 
This renders the introduction of the needle practically painless. A point 
one-half inch to either side of the median line and midway between the 
spinous process is taken, and the needle pushed forward, inward, and 
upward. Special effort is made to keep away from the central part of 
the spinal canal by a close relation of the needle point to the dura. The 
instrument used is of the simplest kind. A small-sized, steel aspirating 
needle with a short-beveled pointed end, having a well-fitted hypodermic 
barrel, answers every purpose. As nearly as possible the same amount of 
cerebro-spinal fluid is allowed to escape as of the injection medium which 
is to be introduced. The injection is given slowly, usually taking one and 
one-half to two and one-half minutes. Often the first evidence that the 
cocaine is taking effect is some dilatation of the pupils or a slight nausea. 

Since the introduction of novocain e we have a much safer local anaes- 
thetic. Owing to its being less toxic than cocaine we do not have the dis- 
agreeable constitutional symptoms so prevalent during the administration 
of cocaine. There is an absence of nausea and vomiting and an absence of 
the dilatation of the pupils. 

The clinical researches of Braun and Bier have demonstrated that 
novocaine produces more profound and more lasting anaesthesia than 



1 The technique of lumbar puncture is described in article on "Meningitis" 
(page 789). 



ANESTHETICS. 893 

cocaine. When applied locally it has no irritating qualities. From one- 
half to 1 cubic centimeter of the 1 per cent, novocaine-suprarenin was suf- 
ficient to procure complete anaesthesia for four hours. 

Novocaine when combined with suprarenin 1 offers our best means of 
producing local anaesthesia. This combination produces far less toxicity 
than cocaine. It is dispensed in tablet form and is readily soluble in 
water. Novocaine produces no by-effects and causes no mydriasis. 

This method has been especially valuable where circumcision is to be 
performed, or where the examination of the bladder is to be made. In 
children I have frequently found considerable nausea and vomiting fol- 
lowing the use of cocaine; the same is also true of eucaine. The analgesic 
effect of eucaine is in some cases as good as that of cocaine. 

Dose Required. — Five, rarely 10 minims of freshly prepared 2 per 
cent, cocaine solution are required. The solution should be freshly pre- 
pared for each case, by dissolving the eucaine or cocaine in sterile water. 
It is well to remember that there are certain toxic effects noted in some 
children. This should be borne in mind, and individual idiosyncrasies 
noted. 



1 Novocaine tablets can be procured in various strengths through Farbwerke 
Hoechst Co., New York. 



CHAPTEE VI. 
DISINFECTION. 

The modern conception of the transmission of such infectious disease? 
as diphtheria, scarlet fever, measles, and cerebro-spinal meningitis has re- 
sulted in a complete reversal of the methods of fumigation, isolation, and 
quarantine. The Health Department of the city of New York has, as recent 
as July, 1913, issued orders that: "On account of the practical absence of 
danger from bedding used by the patient, the removal of such bedding for 
disinfection after the termination of cases of diphtheria, scarlet fever, 
measles, cerebro-spinal meningitis and poliomyelitis should be discontinued. 
In exceptional instances where the family or physician insist upon steriliza- 
tion of bedding, it will still be performed by the department. In special 
cases, where proper and efficient fumigation cannot be performed by reason 
of the nature of the premises, bedding will be removed after the termination 
of these diseases, and bedding will also be removed in cases of small-pox." 

The best disinfectant is sunlight and fresh air. There is no danger 
from the air of the room in which the patient suffering from diphtheria is 
confined. There is danger in the secretions from the nose and mouth, or if 
there is a mouth to mouth contact with a patient suffering from diphtheria. 

The presence of insects in the sick room, especially flies, should be 
guarded against as much as possible, in view of the fact that they may 
act as carriers of the disease. No food should be allowed to stand uncov- 
ered in the sick room, as in certain cases pathogenic organisms may gain 
access and multiply therein. 

Sputa are best disinfected by steam sterilization, together with the 
sputum cups. The addition of 15 grams of sal-soda to a liter of water 
materially aids the process of cleaning. 

Urine and fceces are best treated together by means of milk of lime. 
In this we possess the most valuable agent for the disinfection of typhoid and 
cholera stools. This agent is prepared as follows: To unslacked lime, 
placed in a jar, as much water as it will absorb is added. The unslacked 
lime is stirred up with 4 parts of water to form the milk of lime, and 
this is mixed intimately with the discharges until the mixture gives a strong 
alkaline reaction (tested by litmus paper). 

Chloride of lime, to be effective, must contain 25 per cent, of avail- 
able chlorine. Six ounces to the gallon of water represents the standard 
solution. 

Carbolic acid, unless in combination with sulphuric, and corrosive 
sublimate are not suitable for the disinfection of stools. 

Discharges can also be disposed of by burning after being mixed with 
sawdust. 

Water-closets are best disinfected by chloride of lime solution. 

(894) 



CHAPTER VII. 

THE ADMINISTRATION OF DRUGS TO CHILDREN. 

A few points concerning the use of drugs in children should be 
noted : — 

1. Give the minimum dose of a drug in the beginning of a disease. 

2. Administer the drug in a palatable form. 

3. The soluble tablet triturates should be administered, as they com- 
bine a minimum quantity with solubility and palatability. 

4. Remember the idiosyncrasies of drugs and guard against toxic doses 
by watching the effect of a drug in any given case. 

5. In some specific diseases such as diphtheria, give a sufficient quan- 
tity of antitoxin to obtain a therapeutic result. 

6. Certain drugs, for example, belladonna, calomel, quinine, strych- 
nia, bromoform, and alcohol, when cautiously administered can be given 
in very large doses. It is only necessary to note the physiological effect 
and then to give the drug until its point of tolerance is reached. 

Accuracy in dealing with poisons is very important in children. It 
is surprising to see the difference in size of various teaspoons on the market. 
I advise using a medicine glass, which is graduated with teaspoon, etc. 



(895) 



CHAPTEE VIII. 
LOCAL REMEDIES. 

Cold Compresses. 

Cold compresses may be made out of linen or cheese-cloth folded sev- 
eral times and wrung out in ice-water. If there is any abrasion of the 
skin, 1 part of glycerine should be added to every 5 parts of water. If con- 
stant cold is wanted, compresses should be changed frequently. 

Hot Compresses or Fomentations. 

Hot compresses or fomentations are made by wringing out a piece 
of flannel in hot water. As this is oftentimes hotter than the hands 
can stand, the flannel may be placed in a towel, two ends being kept from 
the water and then wrung out in the towel by twisting the ends. In apply- 
ing fomentations they should not be hotter than can be borne by the face 
of the mother or nurse. To retain the heat they may be covered with oil 
silk, oil paper, or oiled muslin, and then with a dry towel. Eenew when 
cool. 

Poultices. 

A poultice is intended to supply heat for a greater period than a 
fomentation. It should not be more than one-half inch in thickness. 

A flaxseed poultice is made as follows: A sufficient quantity of 
water is heated, and when brought almost to the boiling point, the flaxseed 
meal should be added slowly, stirring all the while to avoid lumping. 
The meal may be added until it has the consistency of hot mush, 
too thick to flow. This may be spread on a piece of linen or cotton 
cloth, the edges turned over slightly and the part to which it is to be 
applied next to the body must be covered with an old handkerchief or 
thin piece of linen. See that it is not hot enough to burn the skin. 
The poultice should be larger than the affected area. Afterward cover 
with oil silk or paper to keep out the air, and then bandage in place. This 
can be renewed every hour or so. Have everything ready when the poul- 
tice is made, as it quickly cools when exposed to the air. 

Turpentine Stupes. 

Turpentine stupes are found very useful in cases of abdominal pain. 
A piece of flannel is wrung out in hot water, the same as in a fomentation, 
(896) 



LOCAL REMEDIES. 897 

except' a little soap or oil added to the water. A little turpentine should 
then be sprinkled evenly over the surface of the flannel, about 30 drops to 
each square foot or a teaspoonful may be added to the water. Apply the 
same as a fomentation. 

Mustard Plasters. 

Mustard plasters for infants should be made with 1 part of mustard 
to 3 or 4 parts of flour or flaxseed meal. Add warm water and stir until 
of the proper consistency. Spread thinly on a cloth and apply directly to 
the skin. It is to be kept on until the skin is reddened, not blistered. 

Ginger Poultice. 

Ginger poultice is made in the same way as that described for the 
making of mustard plasters, and has its advantages in that it will not 
blister. 

Cantharidal Collodion. 

In using the cantharidal collodion care should be exercised to remove 
all moisture and excretions from the skin before applying, otherwise the 
cantharidin, being soluble in water, will not come into contact with the 
skin. One of the most convenient methods of preparing the skin for the 
application of cantharidal collodion is to wash the part with vinegar or 
dilute acetic acid. 

Venesection (Blood Letting). 

Local blood letting is frequently a valuable therapeutic aid, especially 
in meningitis and in cerebral pneumonia, in fact, wherever symptoms of 
cerebral hyperemia are noted. Convulsions are sometimes prevented by 
relieving congestion with the aid of a few leeches. Baginsky reports the 
value of venesection as a routine measure in certain types of diseases, such 
as continued convulsions, in which relief can be afforded by this means. 
The skill of the surgeon is necessary, for we must consider the possibility 
of infection while opening a vein. 

Dry Cupping. 

The application of dry cups is useful in marked dyspnoea. It is there- 
fore indicated in asthma, broncho-pneumonia, and in pulmonary oedema, 
two cups may be applied on each side posteriorly for several minutes. If 
relief is afforded, they can be applied once every twelve hours. 



57 



CHAPTER IX. 
RECTAL MEDICATION IN CHILDREN. 

When" the stomach is irritable in young children I prefer to medicate 
per rectum. The gastric mucous membrane will sometimes show an in- 
tolerance for drugs. It is advisable, especially in exhaustive diseases, such 
as diphtheria, typhoid fever, and the intestinal disorders, to support the 
strength of the body with nutrition. In such cases vomiting may be pro- 
voked by the administration of drugs. Children will frequently object to 
taking medicine, and it is painful to watch the struggle between mother 
and child while attempting to force the medicine into the infant's mouth. 
In such cases, especially in very young infants with whom we cannot reason, 
the rectum should be chosen as the proper channel for the introduction of 
the drug. The rectum absorbs slowly but surely. 

The following drugs may be given per rectum and the doses gradually 
increased : — 

Aconite may be given in suppository, but shows its action only in large 
doses. We must therefore administer it in repeated small doses to obtain 
its effect. For example, we may give 1 or 2 drops of the tincture in a 
suppository to a year-old child. 

Belladonna acts as an excellent sedative in cough, and exerts a very 
favorable influence on the muscle fiber of the intestine. We may use 1 / 6 
minim of extract of belladonna in twenty-four hours, divided into three 
or four suppositories, for every two years of age. 

Bromides should be given in doses of 3 grains for each year of life, in 
two suppositories ; 3 / 4 grain if it is to be continued. In severe spasm we 
may give two grains for each year of life, in two suppositories rapidly fol- 
lowing each other; for example, in laryngismus stridulus. 

Caffeine is usually injected subcutaneously. It may, however, be 
administered in a suppository with equal parts of benzoate of sodium. 
For example, one and one-half grains to a suppository, using two daily 
for each year of the child's life. 

Digitalis. — Powdered digitalis is with difficulty absorbed by the rec- 
tum. The tincture should, therefore, be used. The maximum dose for 
each year of life is 4 drops, divided into two suppositories. 

Iodine and its preparations are exceptionally well borne by the rectum, 
and fully absorbed. Three grains for each year of life, in two supposi- 
tories, is the maximum dose; 3 / 4 grain if it is to be continued. 
(898) 



RECTAL MEDICATION. 899 

Mercury should only exceptionally be given per rectum, and then only 
in the form of calomel, 3 / 4 grain in a suppository for each year of life. 

Nux Vomica. — One-sixth of a grain for every two years, in three sup- 
positories. 

Strychnine should only be given to children over 10 years of age. 

Salicylic Acid. — Seven and three-quarter grains for each year of life, 
in divided doses (three or four). 

Quinine is best given in suppositories. The daily maximum dose is 
2 to 3 V 3 grains, in two suppositories, for each year of life. 

Antipyrine may be given in the same dose as quinine. 

Opium. — Pulvis opii may be given in suppositories, in doses of V 66 
grain for each year of the child's age, and this dose may be repeated in 
severe cases every two hours. 

Toxic symptoms should be carefully watched for, and the use of the 
remedy discontinued on their appearance. These doses are small ones and 
may be increased. 



CHAPTEE X. 

PRESCRIPTIONS FOR VARIOUS DISEASES. 

Fever. 

B Sweet spirit of niter l 1 ^ fl. drachms 610 

Citrate of potassium 30 grains 2j0 

Syrup of lemon . . . . 4 fl. drachms 1510 

Aquae q. s. ad 2 fl. ounces q. s. ad 60 

M. Sig. : A teaspoonful every hour. Repeat 3 doses. 

For a child 3 years old; younger children % teaspoonful. 

1$. Tr. aconite rad 16 drops gtts. 16 

Spir. mindererus 2 ounces 60 

M. Sig.: % teaspoonful every hour. 
For a child 2 to 4 years old. 



To Correct Flatulence — A Mild Laxative. 



IJ Magnesia usta ~. 1 drachm 4 

Pulv. rhei 1 drachm 4 

Saccharum 2 grains 

M. and divide into 12 powders. 

Sig.: 1 powder in a teaspoonful of water every two or three hours. 





12 



Persistent Diarrhea, with Tubercular Symptoms. 

I£ Guaiacol carbonate. 

Sig.: 1 to 2 grains three times a day. 

For a child 1 year old. 



Entero- colitis. 



R- Tinct. kino 20 minims gtts. 20 

Misturae cretae comp 1 drachm 4 

Aqua q. s. ad 2 ounces q. s. ad 60 

M. Sig.: Teaspoonful every three hours. 



Colitis, with Pain. 

Ifc Tinct. opii camph 10 minims gtts. 10 

Bismuthi subnit. 2 grains 

Aquae calcis q. s. ad 4 drachms q. s. ad 16 

M. Sig.: Teaspoonful every two hours. 
(900) 



PRESCRIPTIONS. 



901 



Atonic Dyspepsia, with Constipation. 

IJ Tinct. nucis vomicae 15 minims 

Pulv. rad. ipecacuanha 1 grain 

Pulv. rad. rhei 10 grains 

Sodii bicarbonas % drachm 

Aquae q. s. ad 2 ounces 

M. Sig. : Teaspoonful before each feeding. 

Summer Diarrhea. 

R. Calomel tablets Vio grain 

Sig. : 1 every twenty minutes for three doses. 
For a child 1 to 2 years old. 

Followed by: — 

IJ Mist, rhei et soda 2 ounces 

Sig.: Teaspoonful every hour, for three doses. 

Following day give: — 

Ifc Bismuth betanaphthol. 

Sig.: 5 grains, in water, every two hours. 

Or:—. 

3$ Mist, creta. 

Sig.: Teaspoonful every two hours. 

Or:— 

B Bismuthi subnit. 20 grains 

Misturae cretae comp 4 drachms 

Aquae q. s. ad 2 ounces 

M. Sig.: Teaspoonful every two hours. 

Or: — 

R< Tannalbin or tannigen. 

Sig.: 5 to 10 grains every three hours. 



gtts. 15 




06 

6 


2 





q. s. ad 30 






01006 



3010 



1 

16 

q. s. ad 30 



Broncho -pneumonia. 

I£ Sodium benzoate V 2 drachm 2 j 

Liq. ammon. anisat 1 drachm 4!0 

Syr. prun. virgin 1 ounce 30 JO 

Aquae q. s. ad 2 ounces q. s. ad 60 1 

M. Sig.: Teaspoonful every two hours. 

For child 5 years old. 



902 MISCELLANEOUS. 

Capillaey Bronchitis. 

When expectoration is viscid:- — 

1$ Ammon. carbonat 10 grains 

Syr. senega 4 drachms 16 

Syr. prun. virg 6 drachms 24 

Aquas camph q. s. ad 2 ounces q. s. ad 60 

M.. Sig.: Teaspoonful in water, every two hours. 



Acute Catarrhal Bronchitis. 

B Ammon. muriat 15 grains 1 

Ammon. bromid 20 grains 1 

Syr. liquorit 6 drachms 24 

Tinct. opii camph 2 drachms 8 

Aquse q. s. ad 2 ounces q. s. ad 60 

M. Sig.: y 2 teaspoonful every two hours. 



Stimulating Expectorant. 

Rv Syr. senegse 20 drops gtts. 20 1 

Ammon. carbonat % drachm 2 

Tinct. opii camphorat 3 drachms 12 JO 

Syr. tolutan 5 drachms 20 JO 

Aquae q. s. ad 6 ounces q. s. ad 180 

M. Sig.: Teaspoonful in water every two or four hours. 



Pleurisy. 

For cough with pain on breathing: — 

B Pulv. Doveri 10 grains 0| 6 

Pulv. ext. liquorit 20 grains 1|3 

Sacch. albi 30 grains 2 

M. ft. chart, no. xx. 

Sig.: 1 powder every three hours. 



Pneumonia. 



Reduce fever with tepid baths or packs. 

Daily attention to bowels with calomel or enema. 

Rv Tinct. aconite, 1 drop every hour, until fever is reduced. 

Aid rest at night with: — 

1$. Codeine, V 10 grain. Repeat in three hours if necessary. 

Or:— 

1$ Dover's powder, % to 1 grain. Repeat in three hours if necessary. 



PRESCRIPTIONS. 903 

Erysipelas. 
Streptococcus vaccine, 50,000,000 to 100,000,000. Inject by hypodermic. 



Bacterial Vaccines. 

Vaccine treatment for erysipelas, pertussis, typhoid, and pneumonia, will 
be found on pages 450-454. 



Gastroenteritis. 
Ifc Castor oil. 

Teaspoon ful every two hours, for four doses. 

If diarrhea persists after flushing the colon and washing the stomach, give 
the following: — 
Ifc Eudoxine. 

Sig. : 5 grains every three hours. 
The diet is most important. 



Persistent Vomiting. 

Lavage (stomach washing) with one tablespoonful of salt to a quart of warm 
water (100° F.). Then leave stomach rest at least six hours'. 



Mouth-wash. 
Pulv. acid, boric solution, 1 per cent. 



Stomatitis or Aphtha. 

Ifc Solut. kali permangan., 1 per cent. 

Sig.: Dilute with equal parts warm water. Wash three times a day. 



Enuresis. 



Ifc Ext. rhus aromaticse fl 10 minims gtts. 10 

Syrupi aromatici 20 minims gtts. 20 

Aquae destillatse q. s. ad 1 drachm q. s. ad 4 

Sig.: This amount to be given three times a day. 

Or:— 

IJ Liq. strychninse hydrochloratis 45 minims . gtts. 45 

Liq. atropinas sulphatis 1^ drachms 6 

Syr. aurant q. s. ad 1 ounce q. s. ad 30 

Sig.: 5 drops at night. Increase gradually. 

For a child 14 years old. Younger children in proportion. 



904 MISCELLANEOUS. 

HOOKWOEM. 

P* Eucalyptus oil 2 drops gtts. 2 

Chloroform 1 drop gtt. 1 

Castor oil 2 drachms 8 

M. Sig. : One dose t. i. d. Repeat treatment several days. 

Tapeworm. 

Ifc Chloroform . 10 drops gtts. 10 

Oleores. filis mas l 1 ^ drachms 6 

Syr. ginger q. s. ad 1 ounce q. s. ad 30 

Nephritis. 

R- Potass, citrat 2^ drachms 10 

Ext. buchu fl 2V 2 drachms 10 

Ext. uva ursi rl 1 drachm, 1 scruple 5 

Syr. limonis 2 ounces 60 

Aquae q. s. ad 4 ounces q. s. ad 120 

M. Sig.: Teaspoonful every two to three hours. 



Pertussis. 
P* Phenacetine. 
Sig. : 2 to 5 grains every three hours, by day. 

1$ Codeine. 

Sig.: Ys grain gradually increased to }4 grain, every two to three hours, at 
night, until cough lessens. 

In severe cases: — 

P* Heroin. 

Sig.: V;a grain, given at night. Repeat in two hours. 



Measles. 
-Pre-eruptive stage: — 
Hot bath or dry hot blanket pack. 

P* Spiritus mindererus (freshly prepared) 
Sig.: 1 drachm, in water, every hour. 



When eruption appears: — 

Continue warmth and warm drinks. 

Strict attention to bowels. 

For cough (see R- Acute Catarrhal Bronchitis) 



PRESCRIPTIONS. 



905 



Or: — 

I£ Ammon. bromid 45 grains 

Syr. liquorit G drachms 

Decoct, althse q. s. ad 2 ounces 

Sig. : Teaspoonful every hour, until relieved. 

For a child 1 year old. 



3 
25 

q. s. ad 60 



Scarlet Fever. 
To reduce fever: — 

I£ Tinct. aconiti 20 drops gtts. 20 

Spir. mindereri 2 ounces 60 

Syr. limonis 1 ounce 30 

AI. Sig.: Teaspoonful every hour, until sweating is produced. 

For a child 5 to 12 years old. Younger children, half the dose. 

Itching: — 

B Calamine 1 drachm 4|0 

Ung. aq. rosae 1 ounce 30 

M. et ft. ungt. 

Sig. : Apply over body once or twice a day. 

Stimulant: — 

I£ Camphor 1 gramme 06 

Olive oil 10 grammes 6 

Sig. : Use hypodermically. 

Restoratives: — 

IJ Mist, ferri et ammonii acetatis, 

Glycerini aa 1 fl. ounce aa 30 1 

Aquae q. s. ad 4 fl. ounces q. s. ad 120 

M. Sig.: A teaspoonful or more, in water, every three hours. 

Or Basham's Mixture may be given: — 

R- Tinct. ferri chloridi, 

Acidi acetici dil :aa 1 fl. drachm 

Liq. ammonii acetatis 6 fl. drachms 

Aquae q. s. ad 6 fl. ounces q. 

M. Sig. : Tablespoonful three times a day. 

For a child 6 years old. 



aa 4|0 

24|0 

s. ad 18010 



Scarlet Fever — Nephritis. 
(Diuretic.) 
R- Acet-theocine. 
Sig. : 5 to 10 grains, every three hours. 



Vaginitis Following Scarlet Fever. 
B Solut. argyrol, 25 per cent. 
Sig. : Drop a few drops into vagina with medicine dropper, two or three times 



day. 



906 MISCELLANEOUS. 

Simple Vaginitis. 
1$ Alum, powdered 1 ounce 3010 

Or:— 

IJ Zinc sulphate 1 ounce 3010 

Or:— 

Ifc Borax 1 ounce 30 1 

Sig. : A tablespoonful to a quart of water, to be used as a vaginal injection 

three or four times a day. Apply a sterile pad of cheese-cloth. A fresh pad to be 

applied after each irrigation. 



Tonic After Exhaustive Disease, Such as Pneumonia oe 
Summer Diarrhea. 

R. Ferri pyrophos. 1 drachm 4 

Quininse sulph y 2 drachm 2 

Strych. sulph % grain 

Acid, phosph. dil 2 drachms 8 

Aquse , q. s. ad 4 ounces q. s. ad 120 

M. Sig.: Teaspoonful three times a day. 







015 







Tonic and Restorative. 

IJ Ferri et quininse citrat % drachm 

Syr. hypophos. comp 4 drachms 

Aquse q. s. ad 2 ounces 

M. Sig.: Teaspoonful after each meal. 



2 

16 

ad 60 



Tonic During Chorea. 

IJ Liq. potass, arsenitis % drachm 2 1 

Ferri et ammon. citrat 1 drachm 4 1 

Aquse q. s. ad 2 ounces q. s. ad 60 

M. Sig. : Teaspoonful three times a day. Increase gradually. 



To Abort Acute Tonsillitis. 

1$ Creosote 8 drops 

Tinct. myrrh 2 ounces 

Glycerini 2 ounces 

Aquse 4 ounces 

M. Sig.: Gargle every hour. 

Acute Tonsillitis. 

I£ Tinct. aconit. rad 1 ounce 

Sig.: I drop every hour for six doses. 
For a child 1 to 5 years old. 



gtts. 8 

60 

60 

120 



3010 



PRESCRIPTIONS. 

Milk Cbust. 

I£ Olive oil y 2 ounce 

Castor oil % ounce 

Salicylic acid '. y 2 drachm 

M. Sig. : Apply every six hours until the crusts loosen. 



907 



Eczema Rubrum, 
Salicylic-sulphur paste: — 

B Ac. salicyl 15 grains 

Sulph. depur 1 drachm, 1 scruple 

Petrolati 6 drachms 

Zinci oxidi 2% drachms 

Amyli 2% drachms 

M. Sig.: Apply three times a day. 

Ichthyol ointment: — 

IJ Ammon. sulph. ichthyolat 1 drachm, 1 scruple 

Aq. dest 1 drachm, 1 scruple 

Adeps benzoat % ounce 

Adeps lanae 6 drachms 

M. Sig. : Apply three times a day. 



Erysipelas and Cellulitis. 

IJ Magnesia sulphate 2 drachms 

Aquse 16 ounces 

M. Sig.: Apply as a lotion. 



8 
500 



Burns. 



IJ Picric acid ointment, 1 per cent. 

Sig.: Apply thickly and cover with strips of oiled silk, then steril gauze 
and bandage. 



Eczema. 
Cooling lotions: — 

IJ Pulv. calamini % drachm 

Pulv. zinci ox y 2 drachm 

Glycerini 15 grains 

Aq. calcis 1 ounce 

M. Sig.: Apply three times a day. 



908 MISCELLANEOUS. 

Or:— 

I£ Phenol 20 drops 

Zinc, oxid 3 drachms 

Calamine 2 drachms 

Glycerini 4 drachms 

Liq. plumbi subacet. dil 1 ounce 

Lime-water q. s. ad 6 ounces 

M. Sig. : Apply three times a day. 

To stop itching: — 

IJ Zinc oxide . 2 drachms 

Amylum 2 drachms 

Naphthalan 1 ounce 

M. Sig.: Apply at night. 

Or Unna's Soft Zinc Paste: — 

^ 01. lini, 
Aq. calcis, 
Zinci ox., 
Cretse of each, equal parts. 

M. Sig.: Apply at night. 





gtts 


20 
12 
8 
16 
30 


1- 


s. ad 


180 



30 



Urticaeia — Hives. 
To stop itching: — 

I£ Eesorcin, 
Menthol, 

Phenol aa 15 grains 

Alcohol 7 ounces 

M. Sig. : Apply with cotton. 



ia 1 
200 



Scabies. 

I£ Balsam Peru 1 drachm 4 

Sulphur y 2 drachm 2 

Betanaphthol 10 grains 

Petrolatum 1 ounce 30 

M. Sig.: Apply on affected areas. Repeat three successive nights. 



Hypodermic Medication. 

When immediate relief is required, hypodermic medication should be 
given. The rapid action 1 of hypodermic medication is best shown in giving 
a dose of apomorphia hypodermically for the relief of spasmodic croup. 



CHAPTEE XI. 
Remedies Most Frequently Administered. 

For hypodermic use the dose should be half that used by the mouth. 
For use by rectum the dose should be twice that used by the mouth. 

Dose for Children. — Dr. Young's rule : Add 12 to the age, and divide 
the age by the result. 

Example. — For a child 2 years old, --^ = |. The dose should be 
V 7 that for an adult. 

In giving powerful medicines and opium still smaller doses must be 
used for children. 

TABLE OF DOSES. 

Owing to the toxic effect, drugs marked "*" must be given with greater caution. 



Remedies. 



*Acid, benzoic 

boric 

camphoric (to check night-sweats) . . . 

gallic 

gallic (in albuminuria) 

hydrobromic, diluted 

hydrochloric, diluted 

*hydrocyanic, diluted 

nitric, diluted 

nitrohydrochloric, diluted 

phosphoric, diluted 

salicylic 

sulphuric, aromatic 

sulphuric, diluted 

sulphurous 

tannic 

*Aconitina (white crystals) 

Aloes ;..... 

Aloinum 

Ammonii benzoas 

bromidum 

carbonas 

chloridum 

iodidum 

valerianas 

*Amyl nitris (inhaled or internally) 

Antimonii et potassii tartras (diaphoretic) 

et potassii tartras (emetic) 

oxysulphuret 

Antipyrin 

Apomorphine hydrochloride 

Argenti nitras 

*Arsenii iodidum 

*bromidum ' 



For Child 
Three Years Old. 



to 3 grains. 

to 2 grains. 

to 6 grains. 

to 5 grains. 

to 12 grains. 

to 12 grains. 
- to 4 grains. 
1 drop. 
1 to 4 drops. 
1 to 4 drops. 
1 to 6 drops. 
1 to 4 drops. 
1 to 3 drops. 

1 to 6 drops. 

6 to 12 drops. 
0.4 to 2 drops. 
14)0 to y 300 grain. 
0.4 to 1 grain. 
0.025 to 0.6 grain. 

2 to 4 grains. 

1 to 6 grains. 
0.6 to 2 grains. 

2 to 6 grains. 
0.4 to 3 grains. 
0.4 to 3 grains. 
0.4 to 1 drop. 
0.01 to 0.02 grain. 
0.2 to 0.4 grain. 
0.1 to 0.4 grain. 
0.4 to 3 grains. 
%o to y 3 grain. 
0.035 to 0.1 grain. 
0.003 to 0.02 grain. 
0.003 to 0.012 grain. 

(909) 



910 



MISCELLANEOUS. 



Remedies. 



*Atropinse sulphas 

*Auri et sodii chloridum 

Bismuthi subnitras 

salicylas 

*Bromoformum (in whooping-cough, etc.) 

Caffeine 

Calcii chloridum hydratum 

Calcii lacto-phosphas • • • • 

Camphora 

monobromata 

Cerii oxalas 

Chinoidinum 

Chloral 

Chloralamidum (hypnotic) . 

Chloroformum 

Chrysarobinum (eczema) 

Cinchonidina, and its salts 

Cocaina (locally, % per cent, solution), internally 

Codeina 

*Colchicine 

Confectio sennse 
*Creolin (locally, % to 2 per cent, solution) internally.. 

Creosotum 

Oro ton- chloral 

Cupri acetas 

sulphas ( emetic ) 

*Digitalinum 

*Digitalis 

*Duboisina, and salts 

*Elaterinum (U. S. P., 1880) . . . 

Emetina, and salts ( emetic) 

Ergota 

Ergotinum 

*Eserina, and its salts 

Ethyl chloride (local anaesthetic) 

Fel bovis purificatum 

Ferri arsenas . . . 

bromidum 

carbonas saccharatus . . . 

et ammonii citras 

et ammonii tartras 

et potassii tartras 

et strychnine citras 

hypophosphis .' 

iodidum saccharatum 

lactas 

pyrophosphas 

subcarbonas 

Ferri sulphas . . . • 

sulphas exsiccatus 

valerianas • 

Ferrum dialys 

reductum 

Gaultheria, oil of 

Guaiacol (constituent of creosote) 

Guaiacol carbonas vel benzoas 

Homatropinse hydrobromidum (mydriatic, locally, 0.2 
per cent, to 4 per cent.) 



For Child 
Three Years Old. 



0.0015 to 0.006 grain. 
0.006 to 0.025 grain. 
1 to 12 grains. 
1 to 4 grains. 
1 to 2 drops. 
0.2 to 1 grain. 
1 to 4 grains. 
1 to 2 grains. 
0.6 to 2 grains. 
0.4 to 1 grain. 
0.2 to 2 grains. 
0.6 to 6 grains. 
0.6 to 4 grains. 
3 to 12 grains. 
0.2 to 6 drops. 
0.035 to 0.6 grain. 
1 to 6 grains. 
0.012 to 0.1 grain. 
% to y A grain. 
0.002 to 0.004 grain. 
12 to 24 grains. 
0.1 to 1 drop. 
0.1 drop, gradually in- 
creased. 
0.2 to 1 grain. 
0.025 to 0.1 grain. 
0.012 to 0.05 grain. 
0.003 to 0.006 grain. 
0.025 to 0.4 grain. 
0.0015 to 0.0033 grain. 
0.0035 to 0.016 grain. 
0.025 to 0.05 grain. 
3 to 12 grains. 
0.4 to 1.6 grain. 
0.003 to 0.01 grain. 

1 to 2 grains. 
0.01 to 0.035 grain. 
0.2 to 1 grain. 
0.4 to 3 grains. 
1 to 2 grains. 

1 to 3 grains. 

2 to 6 grains. 
0.2 to 1 grain. 
1 to 2 grains. 
0.4 to 1 grain. 
0.2 to 0.6 grain. 
0.2 to 1 grain. 

1 to 6 grains. 

3 to 5 grains. 

2 to 5 grains. 
2 to 3 grains. 
2 to 3 grains. 
2 to 3 grains. 
0.6 to 2 grains. 
1 to 2 grains. 
0.065 to 2 grains. 



TABLE OF DOSES. 



911 



Commencing doses 

to be 
increased cautiously 



*Hydrargyri chloridum corrosivum 

*chloridum mite 

*Hydrargyri iodidum rubrum 

iodidum vir 

subsulphas flava (as emetic ) 

Hydrargyrum cum creta 

Hydrastine 

Hydrogenii dioxidum (10-volume solution), locally, (25 

to 100 per cent. ) , antiseptic 

*Hyoscinse hydrobromas 

*Hyoscyaminse sulphas 

Ichthyol (locally, 10 to 50 per cent.), internally 

Infusum digitalis 

Iodoformum : 

Iodol 

Iodum 

Ipecacuanha (expectorant) 

Ipecacuanha ( emetic ) 

Jalapa 

Liq. ammonii acetatis 

acidi arseniosi 

arsenii bromidi 

arseni et hydrargyri iodidi. 

potassii arsenitis 

sodii arseniatis 

ferri chloridi ". 

ferri dialys m 

potassii citratis 

Lithii benzoas 

bromidum 

carbonas 

citras 

salicylas ....... 

Lupulinum 

Magnesii carbonas 

citras, gran 

sulphas 

Mangani oxidum niger 

Methylene blue with powdered nutmeg (malarial fevers) 
Mistura chloroformi 

ferri et ammonii acetatis 

glycyrrhizse composita 

potassii citras 

rhei et sodse 

Morphin and its salts 

Morrhuol (derivative of codliver oil) 

Moschus 

Naphthol 

*Nitroglyeerinum ( trinitrin ) , y 2 per cent, solution .... 

Oleoresina aspidii ( filix mas ) 

Opium ( 14 per cent, morphine) 

Phenocoll hydrochloride 

*Phosphorus 

*Pilocarpina, and salts (cautiously) 

Piperazin , 

Plumbi acetas 

Potassii acetas 

bicarbonas 

Potassii bromidum , 



For Child 
Three Years Old. 



0.003 to 0.002 grain. 
0.012 to 2 grains. 
0.004 to 0.02 grain. 
0.035 to 0.2 grain. 
0.4 to 1 grain. 
0.6 to 1.6 grains. 
0.6 to 1 grain. 



0.001 to 0.0035 grain. 
0.001 to 0.003 grain. 
0.6 to 1 grain. 
15 to 30 drops. 
0.2 to 1 grain. 
0.035 to 0.1 grain. 
0.02 to 0.05 grain. 
0.035 to 0.2 grain. 
3 to 6 grains. 
3 to 6 grains. 
15 to 30 drops. 



0.2 to 1 drop. 

2 to 5 drops. 

2 to 6 drops. 
15 to 30 drops. 
1 to 4 grains. 

1 to 4 grains. 
0.4 to 2 grains. 

1 to 4 grains. 

1 to 6 grains. 

1 to 6 grains. 

3 to 12 grains. 
5 to 20 grains. 

2 to 6 grains. 
0.2 to 1 grain. 
0.2 to 1 grain. 
1 to 5 drops. 

5 to 15 drops. 
5 to 15 drops. 
5 to 15 drops. 
10 to 30 drops. 
Yioo to %5 grain. 
10 to 30 drops. 
0.4 to 3 grains. 
0.4 to 1 grain. 
1 to 2 drops. 
1 to 3 grains. 
0.025 to 0.4 grain. 
1.6 to 3 grains. 
0.00L5 to 0.004 grain. 
0.003 to 0.001 grain. 

3 grains (daily). 
0.1 to 0.6 grain. 

3 to 12 grains. 
1.6 to 12 grains. 
1.6 to 12 grains. 



912 



MISCELLANEOUS. 



Remedies. 



Potassii bitartras 

chloras 

cyaniduni 

iodidum 

nitras 

permanganas 

Pulvis antimonialis 

glycyrrhizae compositus 

ipecacuanhae et opii 

jalapae compositus 

rhei compositus . . . 

Resina copaibae 

guaiaci 

jalapae 

podophylli . . . . 

©cammonii 

Resorcin 

Rheum 

Saccharine ( substitute for sugar ) 

Salicinum 

Salipyrin (antipyretic, antineuralgic) ... 

Salol 

Salophen (antipyretic, antirheumatic) . . . 

Santoninum 

Senna 

*Sodii arsenas 

benzoas A 

boras (in epilepsy) 

bromidum 

chloras 

hyposulphis 

iodidum 

phosphas 

salicylas ■ 

*Sparteinae sulphas (cardiant and diuretic) 
Spiritus aetheris nitrosi 

aetheris compositus 

ammoniae aromaticus 

camphorae 

chloroformi 

Strontii lactas vel bromidum vel iodidum 

*Stfychnina, and salts 

Sulphonal (best in hot mint- water) 

Sulphur 

Syr. f erri bromidi ....'. 

ferri iodidi 

scillae compositus 

senegae 

sennae 

Terebene 

Terpin hydrate (tonic expectorant) 

Theobrominae et sodii salicylas (diuretic) 

Thymol 

*Tinctura aconiti 

aloes 

asafoetidae 

belladonnas 

cannabis indicae 

capsici 



Fob Child 
Three Years Old. 



0.2 
1 



to 0.4 grain, 
to 6 grains. 



0.01 to 0.025 grain. 



0.4 

0.4 

0.1 

0.2 

6 

1 

2 

1 

1 






to 6 grains, 
to 3 grains, 
to 1 grain. 

_ to 0.6 grain. 

to 12 grains. 

to 3 grains. 

to 5 grains. 

to 12 grains. 
.4 to 2 grains. 

to 4 grains. 
.4 to 1 grain. 
,016 to 0.1 grain. 
u.4 to 2 grains. 
0.4 to 1 grain. 
0.4 to 6 grains. 
0.1 to 1 grain. 
1 to 6 grains. 
1.6 to 3 grains. 
0.4 to 2 grains. 
3 to 4 grains. 
0.05 to 1 grain. 
1.6 to 36 grainns. 
0.003 to 0.02 grain. 
1 to 3 grains. 
1 to 6 grains. 
1 to 6 grains. 
0.4 to 1 grain. 
1 to 4 grains. 
0.4 to 6 grains. 
0.4 to 24 grains. 
1 to 6 grains. 
0.012 to 0.8 grain. 
3 to 24 drops. 
3 to 24 drops. 
3 to 12 drops. 
1 to 6 drops. 
3 to 12 drops. 
3 to 12 grains. 
0.003 to 0.016 grain. 
1 to 4 grains. 
1 to 5 grains. 
1 to 12 drops. 
1 to 6 drops. 
1 to 6 drops. 

5 to 15 drops. 
10 to 20 drops. 
1 to 3 grains. 
0.4 to 1 grain. 

1 to 6 grains. 
0.2 to 1 grain. 
1 to 2 drops. 
3 to 12 drops. 

6 to 12 drops. 
0.4 to 3 drops. 
1 to 4 drops. 
1.6 to 3 drops. 



TABLE OF DOSES. 



913 



Remedies. 



Tinctura cimicifugae 

cinchonas composita 

colchici seminis 

conii 

*digitalis 

ferri chloridi 

gelsemii 

guaiaci ammoniata 

hydrastis 

hyoscyami 

iodi compositus 

kino 

musk 

nucis vomicae 

*opii 

opii camphorata 

strainonii 

strophanthi ( cardiant and diuretic ) 

Valerianae ammoniata 

veratri viridis 

'Trional (hypnotic) 

Trituratio elaterini ( 10 per cent.) 

Vinum antimonii (expectorant and alterative) 
( emetic ) 

colchici 

ergotae 

ipecacuanha? ( expectorant ) 

(emetic) 

opii 

Zinci acetas 

bromidum 

iodidum 

oxidum 

phosphidum 

sulphas ( emetic ) 

valerianas 



• Foe Child 
Thbee Yeaes Old. 



6 to 12 drops. 
3 to 24 drops. 
1 to 4 drops. 

1 to 6 drops. 
0.6 to 3 drops. 

2 to 6 drops. 
0.4 to 3 drops. 
6 to 12 drops. 
6 to 24 drops. 
1 to 6 drops. 
1.4 to 3 drops. 

3 to 24 drops. 
3 to 12 drops. 
1 to 3 drops. 
0.4 to 3 drops. 
1 to 48 drops. 

1 to 3 drops. 
0.2 to 2 drops. 

2 to 24 drops. 
0.6 to 2 drops. 

3 to 12 grains. 
0.025. to 0.2 grain. 
1 to 5 drops. 

6 to 15 drops. 
1 to 3 drops. 
1 to 5 drops. 
1 to 3 drops. 
5 to 15 drops. 
' to 2 drops. 
0.1 to 0.4 grain. 
0.1 to 1 grain. 
0.1 to 0.6 grain. 
0.2 to 1 grain. 
0.02 to 0.035 grain. 
3 to 6 grains. 
0.1 to 1 grain. 



INDEX. 



Abdomen, 72 
in ascites, 358 
in cretinism, 719 
in dislocation of the hip, 863 
in Henoch's purpura, 708 
in intussusception, 285 
in peritonitis, 354 
in pseudo-leukaemic anaemia, 695 
tapping the, 360 
Abdominal band, 21 

in gastroptosis, 234 
in pertussis, 458 
Abnormal growths, 842 
Abnormalities, congenital, 57 

of air passages, 60 
Abortive pneumonia, 462 
Abscess, complicating Pott's disease, 851 
complicating vaccination, 644 
in angina Ludovici, 216 
in perinephritis, 374, 375 
in pyelitis, 377 
of brain, 804 
of cervical region, 852 
of inguinal region, 852 
of liver, 347 
of loin, 852 
of spine, 852 
of thoracic region, 852 
alveolar, 215 
cerebral, 804 
hepatic, 347 

caused by worms, 291 
ischio-rectal, 295 
peritonsillar, 406, 522 

resembling diphtheria, 522 
retro-cesophageal, 217 
retro-pharyngeal, 415 

complicating scarlet fever, 415 
subphrenic, 351 
Abscesses, in erysipelas, 659 
in typhoid, 654 
multiple, complicating cerebro-spinal 

meningitis, 784 
renal, of urinary passages, 377 
Acetonemia, 380 
Acetonuria, 380 

in diabetes mellitus, 394 
Acid, carbolic, as disinfectant, 894 
hydrochloric, in gastric contents, 66, 

875 
lactic, in gastric contents, 66, 875 
Acidsemia, 3S4 
Acidosis, 132, 235, 384 
Acute milk infection, 256 



Addison's disease, 732 
Adenitis, acute, 712 

chronic, 713 

retro-pharyngeal lymph-, 416 

tubercular, 714 
Adenoid vegetations, 411 

a point of entrance of tubercle bacilli, 
485 

causing deafness, 408 

causing enuresis, 389 

congenital, 59 

face, 412 

method of examining for, 412, 413 

operation, 414 

haemorrhage after, 415 
Adherent prepuce, 363 
Adhesia linguae, 59 
Adhesions, in pleurisy, 436 

in chronic empyema, 443 
Administration of drugs, 895 
Adrenal glands, diseases of, 732 
Adulteration of milk, 119 (see also 

Milk Preservatives, 121) 
Ague (see also Malarial Fever), 662 
Air passages, abnormalities of, 60 
Airing out of doors, 21 
Alalia idiopathica, 806 
Albumin, concentrated preparations of, 
194 

in milk, effect of heat on, 153 

in urine, 878 
test for, 881 

milk, 140 

transformation of, by gastric juice, 
67 

water, 868 
Albuminoids in cows' milk, 138 

in human milk, 76 
Albuminuria, 878 

in malarial fever, 670 

in measles, 588 

in nephritis, 371, 879 

lordotic, 381 

orthostatic, 381 

resulting from exercise, 24 

transient, in scarlet fever, 614 
Albumoscope, 872 
Alcohol, content in liquid foods, 177 

internally, 203 
abuse of, 245 
Almond milk, 868 
Alveolar abscess, 215 

arch, in adenoid vegetations, 411 
Amaurotic family idiocy, 810 
Amoebic dysentery, 251 

(915) 



916 



INDEX. 



Amyloid degeneration, 879 

of the liver, 349 
Attrylopsin ferment test, 226 
Anaphylactic shock, 518 
Anaphylaxis, 428, 517, 589 
Anaemia, 691 

associated with masturbation, 754 

acquired, 691 

congenital, 691 

following diphtheria, 525 

in Addison's disease, 732 

infantum pseudo-leukaemica, 694 

pernicious, 692 

pretubercular, 493 

pseudo-leuksemic, 694 

secondary, 692 

splenic, 691 
Anaemic murmurs, 331 
Anaesthesia, 890 

intraspinal, 892 

local, 892 

partial, in multiple neuritis, 752 
Anaesthetic, in adenoid operation, 414 
in empyema, 442 
in tonsillotomy, 409 

chloroform, 890 

ether, 891 

ethyl chloride, 891 

nitrous oxide, S90 
Analyses of cows' milk, 114, 115 

of woman's milk, 78, 80, 83 
Anaphylaxis, 517 
Anasarca, general, in leukaemia, 694 

in nephritis complicating scarlet fever, 
626 

in post-scarlatinal nephritis, 617 

in tuberculosis of the lung, 481 
Angeioma, 57 
Angina Ludovici, 216 

pseudo-membranosa in scarlet fever, 
608 
scarlatina membranosa, 610 

tonsillaris, 403 
Ani, prolapsus, 296 
Ankle, oedema of, in chlorosis, 696 
Ankle-joint, diseases of, 865 

in rachitis, 311 
Anorexia, in acute tuberculosis, 493 

in measles, 585 

in meningitis, 787 

in rheumatism, 699 

in rubella, 578 
Antibacterial action of the blood, 688 
Anticolic nipple, 151 
Antimeningitis serum, 791 
Antipyretics, in broncho-pneumonia, 433 

in cerebral pneumonia, 474 

in influenza, 450 

in scarlet fever, 619 

in typhoid fever, 655 
Antiscorbutic diet, 145 
Antistreptococcus serum, in erysipelas, 

659, 661 
Antistreptococcus serum, in scarlet fever, 
628 



Antistreptococcus serum, in tubercular 

peritonitis, 358 
Antitoxin anaphylaxis, 517 
diphtheria, 534 
in omphalitis, 35 
eliminated by woman's milk, 82 
in meningitis, 792 
in tetanus, 759 
in typhoid, 655 
rashes, 515 

streptococcus, in erysipelas, 659, 661 
in scarlet fever, 626 
Anus, absence of, 63 
atresia of, 63 

condylomata of, in syphilis, 676 
congenital narrowing of, 63 
fissure of, 294 
Aorta, 331 

area of murmur, 331 
Aortic bruit, 332 

cusps in diastolic murmur, 332 
from aneurism, .332 
systolic murmur, 332 
valves, in diastolic murmurs, 331 
Aphasia, complicating cerebral paralysis, 
798 
complicating diphtheria, 523 
complicating pertussis, 451 
complicating typhoid, 654 
Aphonia, due to paralysis, 4 
in hereditary ataxy, 767 
spastica, intubation in, 554 
Aphthae, Bednar's, 208 
Appendicitis, 278 

differential diagnosis, from abscess 
of ovary, 281 
from colic, 281 
from hip-joint disease, 281 
from intussusception, 281 
treatment, 281 

operation, interval, 282 
catarrhal, 281 

false (see also Pseudo-appendicitis), 282 
gangrenous, 279 
helminthic, 279 
ulcerative, 279 
Appendix, vermiform, location of, 73 
Appetite, in gastroptosis, 232 
abnormal, 231 
loss of, 229 

due to catarrh, 394 
Arm in birth palsy, 44 
Arthritis, 866 

following empyema, 866 
following measles, 866 
following scarlet fever, 866 
following traumatism, 866 
Arthus phenomenon, 518 
Articular rheumatism, 700 
Artificial feeding (see also Bottle or 

Hand Feeding), 150 
Arrhythmia in myocarditis, 343 
Ascaris lumbricoides, 290 
Ascites, 358 

treatment, 359 



INDEX. 



917 



Ascites, treatment, tapping the ab- 
domen, 360 
due to peritonitis, 359 
Asphyxia, during intubation, 553 
in diphtheria, 525 
in pertussis, 457 
in retro-pharyngeal abscess, 416 
neonatorum, 45 
Aspiration ( see Lumbar Puncture ) . 
in ascites, 560 
in encephalocele, 777 
in hydrocephalus, 775 
in nephritis, complicating scarlet 

fever, 621 
of chest in pleurisy with effusion, 438 
of pericardium, 341 
Asthma, bronchial, 428 
dyspeptic, 236 
thymic, 713 
Ataxia, hereditary, 766 
Atelectasis pulmonum, complicating per- 
tussis, 457 
differentiated from pneumonia, 472 
in bronchitis, 426 
in diphtheria, 544 
in premature infants, 33 
Athetosis in cerebral paralysis, 797 
Atomizer, 392 
oil, 418 
steam, 419 
Atony, general, in gastroptosis, 232 

of "intestine, 299 
Atresia ani, 63 
Atrophy, infantile, 321 
urine in, 878 
in acute myelitis, 764 
in multiple neuritis, 752 
in pseudohypertrophic paralysis, 802 
Aura, of epilepsy, 761 

of hysteria, 749 
Auscultation, in asthma, 423 
in bronchitis, 426 

acute catarrhal, 423 
• capillary, 423 
in emphysema, 423 
in fluid or air in pleural sac, 423 
in pleurisy, 423 
subacute, 423 
in pneumonia, 423 
in tuberculosis, 424 
of anterior fontanel, 733 
Auto-intoxication, 285 

Babcock's milk test, 133 
Babinski reflex, 737, 786 

in hereditary ataxia, 767 

in tubercular meningitis, 782 
Bacillary diphtheria of the colon, 252 
Bacillus, of diphtheria, 502 

of Eberth, in typhoid, 464 

of influenza, 396 

of Pfeiffer, 395 
Klebs-Loeffler, 502, 503 

stain for, 889 
pyocyaneus, in bronchitis, 425 



Bacillus, tubercle, 486 

stain for, in sputum, 888 
typhoid, 646 

Vincent's, in ulcero-membranous ton- 
sillitis, 405 
Back-knee in rachitis, 320 
Backwardness, 3 

differentiated from idiocy, 807 
in speaking, 806 
Bacteria, action of gastric juice on, 66 
action of saliva on, 66 
in bronchitis, 425 
in broncho-pneumonia, 430 
in cows' milk, 77 
in cystitis, 387 
in empyema, 387 
in erysipelas, 658 
in follicular tonsillitis, 405 
in measles, 584 
in perinephritis, 374 
in pertussis, 455 
in vaginitis, 366 
in woman's milk, 76 
of intestines, 243 
Bacterial vaccines, 450 
Bacteriological memoranda, 888 
Baginsky tonsillotome, 409 
Baldness of occiput, in rickets, 311 

in scurvy, 306 
Band, abdominal, 21 

in gastroptosis, 234 
in pertussis, 458 
Banti's disease, 691 
Barlow's disease, 301 
Basedow's disease (see also Exophthal- 
mic Goiter), 731 
Basham's mixture, 627 
Basilar meningitis (see also Meningitis), 

• 779 
Bath, at birth, 18 

in diphtheria, 533 
in rheumatism, 703 
in syphilis, 682 
in typhoid, 655, 689 
temperature of, 19 
thermometer, 19 
bichloride, in syphilis, 682 
hot air, 621 

hot and cold, in asphyxia neona- 
torum, 47 
hot, as a diaphoretic, 620 
oatmeal, 19 

spray, in hysteria, 751 
sulphur, in rheumatism, 703 
tub, in typhoid, 655 
Bednar's aphthae, 208 
Bed-wetting, a symptom of phimosis, 
363 
caused bv presence of adenoids, 412 
Beef -juice, *868 
Bell's paralysis, 802 
Benger's food, 191 

Beriberi caused by lack of vitamines, 144 
Bicarbonate of soda solution, 143 
Bifid tongue, 214 



918 



INDEX. 



Bifid uvula, 215 

Bile, 346 

Bile-ducts, congenital obliteration of, 37 

Bilious attack (see also Dyspepsia), 219 

Birth palsy, 43 

Bladder, 378 

extroversion of, 378 

location of, 378 

proper training of, 23 

stone in, 386 

washing, 386, 387 
Bleeders (see also Hemophilia ) , 709 
Blepharitis, 824 

Blindness following meningitis, 791 
Blisters (see also Burns), 839 
Blood, 683 

antibacterial action of, 688 

at birth, 683 

circulation of, during foetal period, 
325 
in early life, 326 

crisis, in pneumonia, ' 467 

effect of antitoxin on, 536 

erythroblasts, 684 

examination of, 667 

to prepare specimen, 651 

in ansemia, 691 

in bronchitis, 685 

in chlorosis, 696 

in diphtheria, 508, 523 

in fever, 689 

in gastro-intestinal diseases, 686 

in hereditary syphilis, 685 

in infectious diseases, 687 

in influenza, 396 

in malarial fever, 662 

in meningitis, 787 

in multiple neuritis, 752 

in nephritis, 371 

in nervous diseases, 686 

in perinephritis, 375 

in pneumonia, 467, 685 

in rachitis, 686 

in scarlet fever, 602, 622 

in skin diseases, 686 

in typhoid, 651 

in Winckel's disease, 41 

inclusion bodies in, 647 

letting, local (see also Venesection), 
897 

pathological conditions in disease, 687 

reaction of pus, 686 

serum treatment in scarlet fever, 628 

test for, in urine, 886 
Blood-vessels (see Thrombosis). 

dilatation of, in angeioma, 57 

in hemophilia, 709 

in spinal paralysis, 768 

in syphilis, 674 
Bloody urine (see also Hematuria), 382 
in diphtheria, 513 
in septic diphtheria, 524 
Blue baby, 333 

Boil (see also Furuncle), 835 
Bone-marrow, in leukaemia, 693 



Bones (see Fractures; also Joints). 
Bones, in hydrocephalus, 776 

in rachitis, 310 

in syphilis, 677 

in tuberculosis, 677 
Borborygmus, 273, 293 
Bothriocephalus latus, 289 
Bottle-brush, 151, 152 
Bottle-feeding, 150 

formulae, 160 

rules for, 158 

utensils required for, 150 
Bottles, feeding, 150, 151 
Bovine tuberculosis, 485, 493 
Bowel movements (see Stools). 
Bowels, inflation of, in intussusception, 
288 

obstruction of (see also Intussuscep- 
tion), 284 

proper training of, 23 
Bow-legs, 3 

in rachitis, 314, 320 
Bradycardia, 330 

in diphtheria, 514 

in myocarditis, 343 
Brain, 778 

abscess of, 804 

concussion of, 811 

engorgement of, in cerebral pneu- 
monia, 475 

in tubercular meningitis, 780 

water on, 774 
Breast-feeding, 84 

dangers of suffocation during, 87 

disturbances during, 88 

schedule for, 84 

suggestions for, 87 
Breast-milk (see also Milk, Woman's), 74 
Breast-pump, 80, 93, 94 
Breasts, massage of, during lactation, 
94 

pear-shaped, best adapted for nursing, 
106 
Breath, in alveolar abscess, 216 

in lithemia, 709 

in pulmonary gangrene, 435 

in stomatitis gangrenosa, 211 
Breathing (see also Respirations), 424 

Cheyne- Stokes, in meningitis, 783 
in tubercular pneumonia, 478 

in bronchial asthma, 428 

in diphtheria, 426 

in dry pleurisy, 437 

in empyema, 440 

in pleurisy with effusion, 438 

in tuberculous pneumonia, 478 

labored, in retro-pharyngeal abscess, 
416 
Breck's feeder for premature babies, 31 
Bright's disease (see also Nephritis), 
370 
urine in, 879 
Bromide, administration of, per rectum, 
896 

of ethyl, as an anesthetic, 891 



INDEX. 



919 



Bronchi, diseases of, 423 

in bronchitis, 425 

in tuberculous pneumonia, 380 
Bronchial asthma, 428 
treatment, 429 

catarrh, 425 

glands, enlarged, 428 
Bronchitis, 425 
treatment, 427 

complicating typhoid, 650 
Broncho-pneumonia, 429 

complicating diphtheria, 522 

complicating measles, 592 

complicating pertussis, 457 

complicating variola, 642 

differential diagnosis from atelectasis, 
433 

fibrous, 433 

physical examination in, 432 

pneumonia jacket, 431 

predisposing causes, 430 

tuberculous, 498 
Broths, 870 
Brudzinski's neck sign in meningitis, 

786 
Buhl's disease, 41 
Bulgarian bacillus, 119, 265 

milk, 174 
Bulimia, 231 

a symptom of hysteria, 231 
Burns, 839 
Buttermilk feeding, 173 

how to prepare, 174 
Butyric-acid test for syphilis, 673 
Byrd method of resuscitation, 46 

Caecum, 73 

Caffeine, effect of, 202 

"Caking" of breast, 94 

Calcium salts, 141 

Calculi, giving rise to bloody urine, 382 

in bladder, 386 

urethral, 386 

vesical, 386 
Calmette tuberculine test, 497 
Caloric method of feeding, 158 
Cancrum oris (see also Stomatitis 

Gangrenosa ) , 210 
Cane sugar, 137 
Cantharidal collodion, 897 
Capillaries in haemophilia, 710 

in malarial fever, 666 
Caput succedaneum, 62 
Carbohydrates, 135 
Carbolic acid as a disinfectant, 909 
Carcinoma, 845 
Cardiac diseases, classification of, 330 

paralysis, 527 

in dysentery, 253 
Carious teeth, in rickets, 312, 313 

possible point of entrance of tubercle 
bacilli, 485 
Casein, 140 

in cows' milk, 77 

in woman's milk, 76, 86 



Casein, in milk, 140 

Casts in urine, in nephritis, 372 

Catarrh, acute nasal, 391 

treatment, 392 
Catarrh, bronchial, 425 

duodenal, 276 
Catarrh, follicular, 404 

gastric, 394 

in syphilis, 675 

naso-pharyngeal, 394 

with adenoid growths, 391 
Catarrhal conjunctivitis, 819 

croup, 417 

jaundice, 228 

nephritis, 614 

pneumonia, 429 

proctitis, 294 
Cavities of the lung, 477, 479 
Cellulitis, complicating vaccination, 644 

of neck, in scarlet fever, 613 
Centrifugal milk-testing machine, 133 
Cephalhematoma, 61 

spurious, 62 
Cereal milk, 185 
Cereals, 164 
Cerebellum, 737 

abscess of, 804 
Cerebral abscess, 804 

congestion, in pneumonia, 475 

haemorrhage, in pertussis, 457 

hernia, 777 

hyperaemia, in insolation, 246 

paralysis, 795 

pneumonia, 464 

thrombosis, complicating diphtheria, 
524 
Cerebro-spinal fluid, 673. (See also 
Spinal fluid.) 

meningitis, 784 
Cerebrum, 737 

Certified milk in New York City, 118 
Cestodes, 289 

Chamomile injections, 274 
Chatillon weight scale, 108 
Chemical examination of cows' milk, 77 
of gastric contents, 875 
of urine, 877 
of woman's milk. 78 
Chest, in broncho-pneumonia, 592 

in cerebral pneumonia, 448 

in chronic pericarditis, 342 

in empyema, 448 

in pleurisy with effusion, 438 

in rachitis, 312 

in spasmodic laryngitis, 418 

strapping of, in dry pleurisy, 437 
in pleurisy with effusion, 439 
Cheyne-Stokes respiration, in tubercular 
meningitis, 786 
in tuberculous pneumonia, 478 
Chicken-pox (see also Varicella), 633 
Childhood, 1 
Chills, in diphtheria, 512 

in orchitis complicating mumps, 717 



920 



INDEX. 



Chills, in perinephritis, 375 

Chloasma, 832 

Chloral hydrate in convulsions, 741 

Chloransemia, 695 

Chloride of lime, as a disinfectant, 894 

Chloroform, 890 

in control of spasms, 741 
Chlorosis, 695 

blood in, 697 
Chocolate and cocoa, 200 

how to prepare, 868 
Cholera infantum, 256 

resembling typhoid, 652 
Cholelithiasis, 348 
Chorea, 744 

causes, 744 

symptoms, 746 

treatment, 747 
Chvostek's phenomena, 757 
Circulation, changes in, at birth, 325 

foetal, 325 
Circumcision, 363 

in treatment of masturbation, 755 

operation for, 364 

tuberculosis infection through, 480 
Cirrhosis of the liver, 350 

splenomegalic, 691 
Cleft palate, 58 
Clothing, 20 

in summer, 20 

in winter, 20 

night, 21 
Clitoridectoiny, in masturbation, 755 
Cocaine as an intra-spinal anaesthetic, 

892 
Cocoa, how to prepare, 200, 868 
Coffee, 202 

Cold, as an antipyretic, 434 
in typhoid, 655 

compresses, 434 

ice collar, in tonsillitis, 403 

pack, in chorea, 748 
in pneumonia, 473 

spray bath, in hysteria, 751 
Colic, a symptom of worms, 290 

in breast-fed babies, 274 

intestinal, 273 
Colicystitis, 385 
Colitis (see also Ileo-colitis), 252 

amoebic, 251, 255 

diphtheritic, 252, 253 

mucous, in syphilis, 675 
Collapse, in diphtheria, 515 
in dysentery, 253 

pulmonary (see Atelectasis Pulmo- 
num). 
Colles's law, 673 
Collodion, cantharidal, 897 

iodoform, in tubercular meningitis, 
783 

salicylic, in mumps, 716 
Colon, bacillus in bronchitis, 426 
perinephritis, 436 

course of, 73 

dilatation of, 272 



Colon, flushing, in intestinal colic, 275 
irrigation of, in diarrhoea, 245 
in dysentery, 266 
in typhoid, 655 
Colored race, mortality in, from tuber- 
culosis, 491 
Colostrum, 74 
Colostrum, corpuscles of, 74 

proteins in, 104 
Coma, in angina Ludovici, 216 
in cerebral pneumonia, 464 
in influenza, 398 
in pachymeningitis, 792 
in scarlet fever, 625 
in tubercular meningitis, 783 
to relieve, 475 
Combustio (see also Burns), 839 
Complement-deviation test in pertussis, 

455 
Composition, of cows' milk, 114 

of woman's milk, compared with dif- 
ferent infant foods,- 193 
Concussion of the brain, 811 
Condensed milk, 179 

causing scurvy, 301 
Condylomata, in syphilis, 676 
Congenital (see also Foetal) abnormali- 
ties, 57 
adenoids, 59 
cysts of the kidney, 62 
dislocation of the hip, 880 
heart lesions, 333 
idiocy, 807 
malformations, 57 

of the rectum, 63 
obliteration of the bile-ducts, 37 
sacral tumor, 62 
stenosis of the larynx, 676 
syphilis, 680, 681 
Congestion of the liver, 347 
Conjunctiva, infection of, 820 

inflammation of, in acute nasal 
catarrh, 391 
Conjunctivitis, acute catarrhal, 819 
cleansing the eye in, 819 
diphtheritic, 820 
membranous, 820 
phlyctenular, 826 
Constipation, 266 
causes, 267 

sterilized milk feeding, 155 
sugar feeding, 137 
treatment, 269 
diet, 270 
alternating with diarrhoea, 229 
in chlorosis, 696 
in cretinism, 719 

to correct, in bottle-fed infants, 130, 
137 
Convulsions, 739 
treatment, 741 
a symptom of worms, 291 
during teething period, 741 
epileptic, 760 
in auto-intoxication, 285 



INDEX. 



921 



Convulsions, in cerebral pneumonia, 464 
in diphtheria, 515, 523 
in dysentery, 253 
in hydrocephalus, 776 
in lithaemia, 709 
in meningitis, 786 
in pachymeningitis, 794 
in pertussis, 457 
in post-scarlatinal nephritis, 617 
in scarlet fever, 605, 606 
in typhoid, 649 
lumbar puncture, 741 
Coprostasis, 299 
Cord, umbilical, management of, 17 

separation of, 1 
Corpuscles of blood, 683 
Coryza, 391 

in measles, 585 
in rubella, 578 
in syphilis, 680 
Cough, in acute tuberculosis, 493 
in croup, 417 
in dry pleurisy, 436 
in pertussis, 456 
in pleurisy with effusion, 438 
in tuberculous pneumonia, 478 
in variola, 642 
croupy, 417, 512 
night, 421 
reflex, 422 
spasmodic, 422 
useless, 422 
whooping, 455 
Coughs of reflex origin, 421 
Counter-irritants, 435 
Cows, breed of, best adapted for infant 
feeding, 114, 116 
care of, 117 

time and stage of milking, 115 
Ayrshire, 116 
Devon, 115 

Durham or shorthorn, 115 
Holstein-Friesian, 116 
Cows' milk, albuminoids in, 138 
care of, 117 
curds in, 139 
properties of, 77 
Coxitis (see also Morbus Coxarius), 

861 
Cranio-tabes, a symptom in rickets, 312 
Cranium (see Skull). 
Cream, 132, 146 

for home modification, 146 
how to procure, 147 
condensed, 179 
dipper, 147 
gauge, 134 
mixtures, 148 
Crede's method of preventing ophthal- 
mia neonatorum, 821 
ointment, in scarlet fever, 631 
in tubercular meningitis, 783 
Cretinism, 719 
etiology, 719 



Cretinism, prognosis and course, 730 

symptoms, 719 

treatment, 730 

thyroid implantation, 731 
Crisis, in pneumonia, 466, 467 

blood, 467 
Croup, catarrhal, 417 
treatment, 418 
emetics, 420 
steam inhalations, 419 

kettle, 420 

spasmodic, 417 
Croupous, enteritis, 252 

oesophagitis, 217 

proctitis, 295 

stomatitis, 209 

tonsillitis, 405 
Crusta la eta, 829 
Cry, as diagnostic aid, 13 

from earache, 13 

from hunger, 13 

in cerebral disease, 13 

in croup, 13 

in marasmus, 13 

in pneumonia, 13 

in tubercular peritonitis, 13 
Cryptorchidism, 365 
Cupping, dry, 897 

in bronchial asthma, 428 
in dry pleurisy, 437 
in hematuria, 3S2 
in meningitis, 791 
in paralysis, 774 
in pneumonia, lobar, 475 
Curvature of the spine, 855 
Cutaneous tuberculin reaction, 496 
Cyanosis, in acute tuberculosis, 493 

in bronchial asthma, 428 

in broncho-pneumonia, 431 

in diphtheria, 545 

in hydropericardium, 343 

in pulmonary tuberculosis, 481 

of nails, in malarial fever, 670 

oxygen in, 371 
Curds, in cows' milk, 139 
Cyclic vomiting, 235 
Cyclops, 778 

Cyst, congenital, of kidney, 62 
Cystitis, 387 

treatment, 389 

Deafness, as a symptom, 408 
caused by adenoids, 412 
following measles, 595 
following meningitis, 791 
following scarlet fever, 620 
with hypertrophy of tonsils, 408 

Decomposition, 321 

Decubitus, 569 

Deficiency diseases, 298 

Deformities, congenital, 57 
in rachitis, 308 

Degeneration, reaction of, 737 

Delirium, in meningitis, 786 



922 



INDEX. 



Dentition, 5 
before birth, 7 
delayed, 7 
difficult, 6 

eruption of first teeth, 7 
in cretinism, 719 
in rachitis, 5 
of first teeth, 7 
of permanent teeth, 7 
Depressed sternum, 61 
Descensus ventriculi, 232 
D'Espines sign in tuberculosis, 494 
Desquamation, following antitoxin rash, 
519 
in measles, 588 
in rubella, 580 
in scarlet fever, 604, 607 
in variola, 640 
Development, mental, in cretinism, 719 
in idiocy, 807 
of body, 5 
of infant, 1 

of the various senses, 2, 3 
Dextrin, 136 
Diabetes insipidus, 383 
Diabetes mellitus, 384 
Diacetic acid test, 886 
Diacetonuria, 380 

Diagnostic points in auscultation, 423 
breathing, 423 
resonance, percussion, 423 

vocal, 423 
rhythm, 423 
suggestions, 9 
cry, 13 

eye aphorisms, 12 
gestures, 13 
pulse-rate, 10 
respiration, 11 
sleep, 14 
temperature, 11 
throat, 13 
tongue, 13 
x-ray, 15 
Diaphoretics, hot-air bath, 626 
hot packj 625 
hot saline injections, 627 
oiled-silk jacket, 477 
Diaphyses, scurvy, 66 
Diarrhoea, 244 

as a symptom of disease, 245 
complicating measles, 596 
in diphtheria, 515, 526 
in malarial fever, 670 
in syphilis, 675 
in typhoid, 649, 653 
fat, 241 
nervous, 245 
summer, 262 
Diastase, 167 

test for, 227 
Diastatic enzyme, in human milk, 63 
in intestinal contents, 82 
in stool of nursling, 82 
Diastolic murmurs, 331 



Diazo reaction, in tuberculosis, 493 
Diet (see Feeding), 
antiscorbutic, 145 
from 1 year to 15 months, 162 
from 18 months to 3 years, 163 
from 3 years to 10 years, 163 

articles allowed, 164 

articles forbidden, 165 
in acute gastric catarrh, 222 
in auto-intoxication, 285 
in chlorosis, 697 
in constipation, 270 
in diarrhoea, 246 
in diphtheria, 539 
in dysentery, 253 
in gastritis, chronic, 229 
in gastro-duodenitis, 228 
in intestinal indigestion, 227, 363 
in lithssmia, 709 
in pellagra, 255 
in pleurisy with effusion, 439 
in pyelitis, 378 
in rachitis, 230 

See Vitamines, 144 
in scarlet fever, 702 
in scurvy, 302 

See Vitamines, 144 
in tonsillitis, 404 
in tuberculosis, 497 
in typhoid, 656 
in ulcer of the stomach, 235 
of a nursing mother, 94, 96 
of a wet-nurse, 103 
salt-free, 624 
Dietary, 868 

Diffuse cellulitis, in scarlet fever, 613 
Digestive system, diseases of, 205 
Dilatation of the colon, 272 
Dilatation of the stomach, 230 

in chronic gastritis, 228 
Diphtheria, acute, 502 
bacillus, 502, 503, 505 

in bronchitis, 425 

Klebs-Loeffler, 503 

characteristics of, 504 
growth on blood serum, 505 

true and false, 506 
bacteriology, 503 

mixed infection, 538 

mode of infection, 502, 504 
chronic, 541 

isolation in, 542 

treatment, 577 
complications, 523 

anaphylaxis, 5 17-, 556 

measles, 596 

omphalitis, 35, 512, 526 

paralysis, 524, 540 

scarlet fever, 608, 628 
course, 511, 528 
diagnosis, 519 

how to take a culture, 519 

premembranous stage, 519, 520 
differential diagnosis, 521 
etiology, 502 



INDEX. 



923 



Diphtheria, extubation, 572 
follicular forms, 515 
immunization in, 531 
intubation in, 542 
isolation, 530 
mild, 512 
nasal, 513 
pathology, 507 
blood, 508 
haemorrhag 
lesions, 507 
lymph-nodes, 508 
Diphtheria, pathology, membrane, 507 
predisposing factors, 502 
prognosis, 437 
prophylaxis, 529 
pseudo or false, 500 

mortality, 501 
septic, 512 
symptoms, 511 

toxin, effect of, on nervous system of 
animals, 510 
on heart, 511 
tracheotomy, 574 
treatment, 533 
antitoxin, 539 
dietetic, 538 
hygienic, 524 
medicinal, 539 
Diphtheria antitoxin, 539 
immunizing dose, 531 
influence of, on mortality, 546 
in treatment of membranous oph- 
thalmia, 807 
limitations of, 531 
manner of administering, 534 
rashes, 515 

anaphylaxis, 517 
desquamation following, 519 
site of eruption, 517 
Diphtheritic colitis, 251, 252 
conjunctivitis, 821 
dysentery, 252 
oesophagitis, 217 
omphalitis, 35, 512 
paralysis, 526, 527 

simulating anterior poliomyelitis, 
527 
rhinitis, 511 
stomatitis, 209 
Diphtheroid, 500 
Diplegia, haemorrhage causing, 736 

spastic, 795 
Diplo-bacillus of Morax, 820 
Diplococcus, Fraenkel, in broncho-pneu- 
monia, 430 
in lobar pneumonia, 461 
intracellulars, 787 
pneumonias, 430 

in broncho-pneumonia, 430 
in pleurisy with effusion, 430, 437 
stain for, 889 
Disease, diagnosis of, 10, 12 
peculiarities of, 9 
symptoms of, 9, 12 



Disinfection, 894 

in diphtheria, 528 

in infectious diseases, 894 

in scarlet fever, 623, 895 

in typhoid, 656 

in variola, 642 

of sputa, 895 

of urine and faeces, 895 

of water closets, 895 
Dislocation of the hip, congenital, 862 
Displacement, of the heart, 842 

of the liver, 348 

of the spleen, 352 

of the stomach, 232, 234 
Diverticulum, Meckel's, 37 
Dobell's solution, 393 
Drager pulmotor, 48 
Drop foot in paralysis, 773 
Dropsy (see also (Edema and Anasarca) 

of the feet, in leukaemia, 694 
Drug eruptions, 617 

resembling measles, 596 
Drugs, administration of, 895 
per rectum, 898 

dosage of, 909 

effect of, on woman's milk, 88 

in treatment of constipation, 269 
Dry cupping (see also Cupping), 897 
Dry pleurisy, 436 
Dry-tap in lumbar puncture, 790 
Ductless glands, diseases of, 719 
Ductus arteriosus Botalli, 334 

closure of, 326 
Duke's disease, 583 
Duodenal bucket, 224 

catarrh, 276 
Dura mater, inflammation of, 794 
Dysentery, 251 

pathology, 251 
symptoms, 253 
treatment, 254 

amoebic, 251 

diphtheritic, 252 
Dyspepsia, 168, 219 
Dyspeptic, asthma, 236 
Dyspnoea, in broncho-pneumonia, 434 

in croup, 418 

in dilatation of stomach, 231 

in diseases of thymus, 691 

in dry pleurisy, 437 

in hydropericardium, 343 

in lobar pneumonia, 475 

in papillomata, 846 

in pulmonary tuberculosis, 481 

in retro-pharyngeal abscess, 416 

in toxic scarlet fever, 606 

in tuberculous pneumonia, 478 

oxygen in, 476 
Dysuria, 881 

Ear, diseases of, 812 

foreign bodies in, 818 

syringe, 814 
Earache, in diphtheria, 538 

in scarlet fever, 628 



924 



INDEX. 



Ears, bleeding from, in diphtheria, 524 
in diphtheria, 515, 523 
in scarlet fever, 628 
inflammation of, in otitis, 812 
running, in syphilis, 680 
Eberth's typhoid bacillus, 646 
Ecchymoses, in purpura, 705 
in purpura hemorrhagica, 706 
in scurvy, 303 
Eclampsia (see also Convulsions), 739 

in epilepsy, 760 
Ectogenous streptococcus infection, 658 
Ectopia vesicae congenitalis, 378 
Eczema, 827 

associated with chronic gastritis, 229 
bathing in, 828 
in lithsemia, 709 
intertrigo, 829 
rubrum, 829 
Effusion, in ascites, 359 
in hydrocephalus, 774 
in nephritis following scarlet fever, 

626 
in pericarditis, 340 
in pertussis, 457 

in pleurisy, 438 • 

Eggs, nutritive value of, 199 
Eiweiss milch, 140 
Elbow-joint disease, 865 
Electricity, in cerebral paralysis, 800 
in chorea, 748 
in constipation, 272 
in enuresis, 390 
Emaciation, in dilatation of the stom- 
- ach, 231 
in gastritis, 229 
in hydrocephalus, 776 
in myelitis, 764 
in tuberculosis, 493 
Embolism, in endocarditis, 338 

in diphtheria, 524 
Embolus, in endocarditis, 337 
Emetics, in bronchitis, 427 
in croup, 444 

in dyspnoea or broncho-pneumonia, 434 
in gastric catarrh, 220 
Emphysema, complicating diphtheria, 544 

complicating pertussis, 457 
Empyema, 439 

complicating diphtheria, 523 

complicating measles, 595 

James apparatus for expanding the 

lungs in, • 443 
of the mastoid antrum, complicating 

scarlet fever, 610 
treatment, 443 

Kenyon's syphon drainage, 442 
surgical, 442 
chronic, 443 
tubercular, 444 
Enanthem, in scarlatina sine angina, 
608 
in scarlet fever, 604 
in measles, 586 
Encephalocele, 777 



Enchondromata, 846 
Endocarditis, 335 

complicating chorea, 746 
complicating diphtheria, 523 
complicating rheumatism, 700 
following scarlet fever, 624 
following typhoid, 654 
symptoms, 336 
treatment, 338 
malignant, 338 
Enemata (see Rectal Irrigations), 
in chronic gastritis, 228 
in constipation, 269 
nutrient (see Rectal Feeding). 
oxgall, 228 
Enteralgia, 273 
Enteritis, croupous, 252 

membranous, complicating diphtheria, 

525 
tuberculous, 486 
Enuresis, 389 

a svmptom of faulty metabolism, 

299 
a symptom of lithsemia, 709 
causes, 389 

adenoids, 389, 412 
tight prepuce, 389 
in meningitis, 786 
prognosis, 389 
treatment, 389 
diurna, 389 
nocturna, 389 
Enzymes, 145 

Eosinophils, in pneumonia, 687 
in scarlet fever, 687 
in skin diseases, 687 
in syphilis, 687 
Epidemic cerebro-spinal meningitis, 784 

hysteria, 750 
Epilepsy, 760 
aura in, 761 
differential diagnosis, 762 

from hysteria, 762 
etiology, 760 

following convulsions, 760 
predisposing factors, 760 
symptoms, 762 
treatment, 763 
grand mal form, 761 
idiopathic, 760 
petit mal form, 761 
Epiphyses, in rachitis, 314, 315, 316 

in syphilis, 681 
Epiphysis, acute, 866 
Epispadias, 365 
Epistaxis, in haemophilia, 710 
in measles, 598 
in pertussis, 455 
in pulmonary tuberculosis, 481 
in septic diphtheria, 513 
in thrombosis of cerebral sinuses, 818 
in toxic scarlet fever, 606 
Epithelial desquamation of the tongue, 
214 



INDEX. 



925 



Erb's paralysis, 43, 774 
Eructations, in chronic gastritis, 229 

in gastroptosis, 232 
Eruption, artificial, 20 

drug, resembling measles, 596 
following injection of diphtheria anti- 
toxin, 516 
in chloasma, 878 
in measles, 585, 893 
in meningitis, 786 
in poliomyelitis, 771 
in rubella, 578 
Eruption, in scabies, 841 
in scarlet fever, 608 
in stomatitis aphthosa, 206, 207 
in syphilis, 676 
in typhoid, 651 
in vaccinia, 645 
in varicella, 633 
in variola, 639 
Erysipelas, 658 
blood in, 687 
complications, 746 
in the new-born, 55 
treatment, 661 
vaccine, 452, 660 
migrans, 659 
Erythema, 830 

differentiated from syphilis, 676, 830 
following injection of diphtheria anti- 
toxin, 516 
on buttocks, 829 
Erythroblasts, 684 
Erythrocytes, 683 
Eskay's albuminized food, 188 

analysis of, 189 
Estlander's operation in chronic em- 
pyema, 444 
Ether as an anaesthetic, 891 
Ethyl chloride, 891 
Eucasin, 194 

Eustachian tube, in adenoid vegeta- 
tions, 411 
in otitis media, 812 
inflammation of, in rhinitis, 299 
Examination of heart, 326 
of lungs, 423 
of patient, 9 
radiographic, 16 
Exercise (see also Gymnastics), 23 
in constipation, 27 i 
in lithsemia, 709 
Exophthalmia in thrombosis of cerebral 

sinuses, 818 
Exophthalmic goiter, 731 

treatment, 731 
Exophthalmus, in exophthalmic goiter, 
731 
in hydrocephalus, 775 
Expectorants, in broncho-pneumonia, 435 
Expectoration (see Sputum). 
in bronchitis, 426 
in pulmonary tuberculosis, 4S1 
in ulcer of stomach, 234 



Exploratory puncture, in empyema, 440 
in pleurisy with effusion/ 438 
points to be noted in making, 440 
Exstrophy of the bladder, 378 
Extubation, 572 

auto-, 543 
Eye, as a diagnostic aid, 12 

diseases of, 819 

in chlorosis, 696 

in chorea, 745 

in distinguishing the still-born from 
the dead, 46 

in exophthalmic goiter, 731 

in gonorrhoea 1 infection, 368 

in measles, 585, 595 

in meningitis, 783 

in nystagmus, 7S6 

in stomatitis gangrenosa, 210 

prophylaxis and treatment of, in the 
new-born, 34 

suffusion of, in rubella, 578 
Eyelid, in blepharitis, 824 

in hordeolum, 825 

in purulent ophthalmia, 821 

in trachoma, 824 

method of everting, 825 

proptosis of, in scurvy, 303 

Face, cyanosis of, in broncho-pneumonia, 
431 
in adenoid vegetations, 411 
in chlorosis, 696 
in cretinism, 719, 720 
in diphtheria, septic, 512 
in nephritis, 372 
in pertussis, 456 
Facial paralysis, following mastoid op- 
eration, 802 
in retro-pharyngeal abscess, 802 
in the new-born, 802 
Faecal vomiting, 286 
Faeces (see Stools). 
Fainting (see Syncope). 

in leukaemia, 694 
Fat, absorption of, 74 

cream gauge for, 134 
Feser's test, 134 
Marchand's test, 134 
in breast milk, 104 
to decrease, 104 
to increase, 104 
in cows' milk, 132 

excess of, 132 
in stool, 132 
Fatty degeneration of blood-vessels, 796 
of newly born, 41 
in pernicious anaemia, 692 
growths, 846 
heart, 330 
liver, 349, 350 
Faulty metabolism, 298 
catarrhal tendencies, 299 
lienteric stools, 298 
nervous manifestations, 299 
scybalous stools, 298 



926 



INDEX. 



Faulty treatment, 299 
Feehle-mindedness (see also Idiocy and 

Imbecility), 806 
Feeding (see Diet and Gavage). 

bottle or hand, 150 
utensils required, 150 

breast, 84 

buttermilk; 173 

caloric method of, 158 

Casselberry method of, in intubation, 
556, 557 

cows' milk, 150 

cream, 146 

flour-ball, 166 

from 1 year to 15 months, 107 

goats' milk, 173 

in atrophy and chronic gastritis, 229 

in bronchitis, 427 

in cleft palate, 58 

in diphtheria, 538 

in hypertrophic pyloric stenosis, 227 

in intubated cases, 556 

in myocarditis, 345 

in pertussis, 459 

in pneumonia, 477 

interval of, 84, 86 

malt soup, to make, 160 

maternal, 85 

mixed, 87 

of premature infants, 30 

rectal, 427, 539 
Feeding bottles, 150 
Femur in rachitis, 314 
Ferment, lipolytic, 82 

tests, 225 
Fermentation, in chronic gastritis, 228 

in auto-intoxication, 285 

test in urine, 885 
Ferments and their actions, 67 

unorganized, 66 
Feser's lactoscope, 134 
Fever (see also Temperature), 445 
causes, 445 

hay, 428 

how to reduce, 474 
hysterical, 447 
in faulty metabolism, 299 
in gastric catarrh, 223 
in tonsillitis, 407 
Fingers in cretinism, 719 
First attempts at walking, 2 
Fissure of the anus, 294 
Fistula in alveolar abscess, 216 
Flatfoot, 854 

Flatulence, in gastro-duodenitis, 226 
Flaxseed poultice, 896 
Flexner anti-meningitis serum, 791 
Flour-ball feeding, 166 
Focal necrosis, 350 

Foetal (see also Congenital) circulation, 
325 

ichthyosis, 50 

typhoid, 647 
Foetus, in syphilis, 672 
Follicular forms of diphtheria, 515 



Follicular forms of tonsillitis, 404, 522 

resembling diphtheria, 521 
Fomentations, 896 
Fontanel, 733 
anterior, 733 
in cretinism, 719 
in hydrocephalus, 776 
in rachitis, 308, 312 
posterior, 733 
premature closure of, 733 
Food, dextrinized, 167 
method of preparing, 167 
intoxication, 255 
Foods, infant, 182 
patent, 181 

composition of, compared with 
human milk, 193 
Foot and mouth disease (see also Stoma- 
titis Aphthosa), 206 
Foramen Magendie, in hydrocephalus, 
736 
ovale, closure of, 326 
Foreign bodies in the ear, 818 
in the larynx, 421 
in the nose, 402 
in 1 the oesophagus, 218 
Formaldehyde in milk, 119 

test for, 119 
Formulae for bottle-fed infants, 161 
Fourth disease, 583 
Fractures, 43 
during labor, 43 
green-stick, 43 
in rachitis, 314 
Fraenkel diplococcus, in lobar pneu- 
monia, 461 
Freckles, 834 

Friedreich's disease (see also Hereditary 
Ataxy), 767 
sign, in chronic pericarditis, 342 
Fright, causing chorea, 745 
causing convulsions, 739 
Furuncle, 835 

differential diagnosis from carbuncle, 

835 
in rachitis, 835 
in syphilis, 676 
vaccine treatment, 451, 835 

Gall-bladder, congenital absence of, 37 
Gall-stones, 348 
Gangrene, 839 

complicating erysipelas, 659 

complicating pneumonia, 472 

complicating typhoid, 654 

of cheeks, 210 

of genitals, 211 

of mouth, 654 

pulmonary, 482 

superficial, 839 

symmetrical, 841 

traumatic, 840 
Gastric catarrh, 219 

contents, examination of, 875 

fever, resembling typhoid, 654 



INDEX. 



927 



Gastric juice, chemical constituents of, 
65 . 
influence of, on pathogenic germs, 
66, 67 
Gastritis, acute, 219 

complicating diphtheria, 524 
chronic, 228 
treatment, 229 
Gastrodiaphane for translumination of 

stomach, 231 
Gastro-duodenitis, 228 
Gastroenterostomy in spasm of the 

pylorus, 224, 226 
Gastro-intestinal disturbance, causing 
asthmatic attacks, 428 
haemorrhage, 41 
tract, in syphilis, 675 
Gastroptosis, 232 
Gavage, apparatus for, 31 
in cleft palate, 58 
in intubated cases of diphtheria, 556 
method of, in premature infants, 32 
Gelatine food, 871 
General hygiene of the infant, 17 
Genital organs, diseases of, 361 
in phimosis, 363 

irritation in chronic cystitis, 387 
Genu recur vatum, 320 

varum (see also Bowlegs), 320 
Geographical tongue (see also Epithelial 

Desquamation ) , 214 
Gerhardt's iron chloride reaction, 886 
German measles, 577 
Gestures as diagnostic aid, 13 
Ginger poultice, 897 
Gingivitis, 6 

in scurvy. 303 
Gland, thymus, 711, 712 

thyroid, 719 
Glands, adrenal, 732 

bronchial, in broncho-pneumonia, 432 
enlarged, causing bronchial asthma, 
428 
cervical, 299 

causing torticollis, 705 
in stomatitis gangraenosa, 211 
diseases of, 711 
in adenitis, 712 
in eczema, 827 
in leukaemia, 693 
in mumps, 716 
in rubella, -578 
in scarlet fever, 604, 628 
in status lymphaticus, 711 
peripheral, in acute tuberculosis, 493 
submaxillary, in diphtheria, 512 
in scarlet fever, 604 
Glomerulo-nephritis, 370 
Glossitis, 215 

Glottis, oedema of, in erysipelas, 660 
in scarlet fever, 631 
in variola, 642 
spasm of, causing cough, 421 
Glucose in urine, 884 
Glycosuria, 383 



Glycosuria, in diabetes mellitus, 384 

in pseudo-hypertrophic paralysis, 880 
Goats' milk, 173 
Goiter, exophthalmic, 731 

wet-nurse with, 98 
Gonococcus, 367 

in cystitis, 387 

in gonorrheal vaginitis, 367 

stain for, 889 

vaccine, 452 
Gram's solution, 889 
Granular gastritis, 228 

ophthalmia, 822 
Granular ophthalmia from false or fol : 

licular granulations, 823 
Granuloma, 35 
Granulomata, 847 

Graves's disease (see also Exophthalmic 
Goiter), 731 

sign in bronchitis, 426 
Grippe (see Influenza), 395 
Growing pains, 699, 701 
Growth and height, 5 

in diabetes insipidus, 383 
Growths, malignant, 842 

non-malignant, 842 
Guaiacum test for blood in urine, 886 
Gums, bleeding, in purpura haemor- 
rhagica, 706 

inflamed, 6 

possible source of invasion of 
tubercle bacilli, 485 

in scurvy, 303 

in stomatitis gangraenosa, 211 

in toxic scarlet fever, 620 
Gymnastics (see also Exercise), 23 

in lateral curvature, 859 

pulmonary, 498 
in empyema, 443 
in tuberculosis, 498 

Habit-spasm, differential diagnosis from 

true chorea, 746 
Haematoma of the sterno-mastoid, 61 
Haematuria, 382 

in cystitis, 387 

in malarial fever, 670 

in purpura haemorrhagica, 706 

in pyelitis, 379 

in scurvy, 302 

in symmetrical gangrene, 841 
Haemoglobin, at birth, 684 

in diphtheria, 510 

in rachitis, 684 
Haemoglobinuria, 382 

in malarial fever, 676 

in symmetrical gangrene, 841 

in syphilis, 880 

in Winckel's disease, 880 

neonatorum, 40 

paroxysmal, 382 
Haemophilia, 709 . 
Haemoptysis, in chronic tuberculosis, 481 

in purpura haemorrhagica, 706 
Haemorrhage, cerebral, in pertussis, 455 



928 



INDEX. 



Haemorrhage, following adenoid opera- 
tion, 415 
following operation for peritonsillar 

abscess, 407 
following tonsillotomy, 408 
from bowels, 694 
from genital tract, 382 
from kidney, 382 
from stomach, 694, 731 
gastro-intestinal, 41 

serum injections in, 42 
in congenital obliteration of the bile 

duct, 38 
in diphtheria, 513, 524 
in leukaemia, 693 
in pachymeningitis, 794 
in syphilis, 765 
in typhoid, 653 
into subarachnoid space, 736 
spontaneous, 39 
subcutaneous, in scarlet fever, 506 

in scurvy, 303 
umbilical, 40 
Hemorrhagic diseases of the newly 

born, 39 
Haemorrhoids, 298 
Hair, 1 

in cretinism, 719 
Hand-feeding (see also Bottle-feeding), 

150 
Hands, disinfection of, 894 

in cretinism, 720 
Harelip, 58 
nipple, 58 
Hay fever, 428 

resembling bronchial asthma, 428 
Head, circumference of, at birth, 733 
in hydrocephalus, 776 
in rachitis, 308 
nodding, in spasmus nutans, 743 
retraction of, in cerebro-spinal menin- 
gitis, 786 
shape of, 733, 734 
supplementary, 62 
sweating, 311 
Headaches, 742 

due to brain lesions, 743 

to general systemic conditions, 742 
to influenza, 396 
to local origin, 742 
in chlorosis, 696 
in chronic gastritis, 229 
in diabetes insipidus, 383 
in lithaemia, 709 
in tubercular meningitis, 783 
reflex, 742 

sick (see also Migraine), 743 
Heart and foetal circulation, 325 
Heart, 325 

diseases of, 329 
displacement of, 842 
effect of exercise on, 24 
examination of, 327 
area of dullness, 328 
location of apex beat, 326 



Heart, fatty, 330 
in chorea, 747 
in diphtheria, 541 
in gonorrhoeal infection, 368 
in pertussis, 456 
in rheumatism, 700 
in scarlet fever, 617, 620 . 
murmurs, 330 
anaemic, 331 
diastolic, 331 
pericardial, 333 
systolic, 330 
venous, 332 
palpitation of (see also Tachycardia), 

330 
position of, 327 
primary tuberculosis of, 486 
reflex symptoms of, 330 
size of, 326 

sounds and murmurs, 330 
tension, 327 

tricuspid insufficiency, 331 
weight of, 326 
Heat-stroke (see also Insolation), 246 
Hehner's test for formaldehyde in milk, 

120 
Height, 5 

Heliotherapy, 15, 498 
Heller's test for blood in urine, 886 
Hemichorea, 746 

Hemicrania (see also Migraine), 743 
Hemiplegia (see also Cerebral Paral- 
ysis), 795 
complicating diphtheria, 523 
haemorrhage into subarachnoid space 
causing, 736 
Hemostatics in acute tuberculosis, 498 

in internal haemorrhage, 42 
Hepatic abscess, caused by worms, 290 
Hereditary ataxy, 766 

syphilis, 680 
Hernia, 361 

differential diagnosis from hydro- 
cele, 362 
in the new-born, 361 
umbilical, 288 
truss, 289 
Herpes, circinatus, 837 
tonsurans, 837 
zoster, 831 
Hiccough (see Singultus). 
Hinged bucket for extracting foreign 

bodies, 218 
Hip, congenital dislocation of, 862 
bilateral dislocation of, 863 
unilateral dislocation of, 863 
Hip- joint disease (see also Morbus 
Coxarius), 861 
from perinephritis, 375 
tubercular, 861 
Hips, in lateral curvature of the spine, 

855 
Hirschsprung's disease, 272 
Hives (see also Urticaria), 830 
Hoarseness, in syphilis, 680 



INDEX. 



929 



Hodgkin's disease, 716 
Home modification of milk, 150 
Hookworm disease, 293 
Hordeolum, 825 
Horismascope, 882 
Horlick's food, 185 
lunch tablets, 164 
malted milk, 184 
Hot-air bath, 621 

compresses or fomentations, 896 
Hot and cold bath, in asphyxia neona- 
torum, 47 
Human, blood serum, 39 
milk ( see Woman's Milk ) . 
diastatic enzyme in, 82 
new reaction of, 82 
properties of, 76 
to preserve, 83 
Humanized milk, 192 
Hutchinson's teeth, 676 
Hydrencephalocele (see also Meningo- 
cele), 777 
Hydrencephaloid, 308 
Hydrocele, 363 
Hydrocephalus, 776 
"external, 776 

foramen Magendie in, 736 
internal, 776 
intra-uterine, 777 
spurious, 308 
Hydrochloric acid, function of, in stom- 
ach, 66 
in gastric contents, 875 
test for formaldehyde in milk, 120 
Hydropericarditim, 343 
Hygiene, of infant, 17 
fresh air, 21 
proper training, 23 
of mouth, 17 
nervous svstem, 23 
stable, 126, 127 
Hyperemia, cerebral, in insolation, 250 
Hyperesthesia, in acute myelitis, 764 

in multiple neuritis, 752 
Hypernephroma, 845 
Hyperorexia (see also Bulimia), 232 

in acute tuberculosis, 493 
Hvperthvrea (see also Exophthalmic 

Goiter), 731 
Hypertrophic pyloric stenosis, 226 
gastro-enterostomy in, 227 
tonsillitis, 405 
treatment, 409 
Hypertrophy of muscles, 802 
of tongue, 214 
of tonsils, 407 
Hypodermic medication, 908, 909 
in spasmodic laryngitis, 420 
Hypodermoclysis, in scarlet fever, 626 

in typhoid, 655 
Hypospadias, 365 
Hysteria, 749 

differential diagnosis from epilepsy, 

762 
pathology, 749 



Hysteria, treatment, 750 

epidemics of, 750 
Hysterical fever, 450 

Ice-bag, throat, 404, 407 
coil, in meningitis, 7S3 
Ice cream, 201 
Ichthyosis, foetal, 50 
Icterus, 346 

complicating pseudo-leuksemic anae- 
mia, 695 
complicating scarlet fever, 619 
urine in, 878 
neonatorum, 52 
Idiocy, 806 

congenital, 807 

infantile amaurotic family, 810 
Mongolian, 807 
Ileo-colitis (see also Dysentery), 251 
Imbecility, 806 
Immunity conferred by woman's milk, 

82 
Immunization in diphtheria, 531 
Imperforate rectum, 63 
Imperial granum, 187 
Impetigo, 833 

resembling varicella, 635 
resembling variola, 641 
Improper nutrition, 298 
Inclusion bodies in blood of scarlet fever, 

602 
Incubators, 27, 33 
Indican, in tuberculosis, 493 

test for, in urine, 884 
Indicanuria, 289, 380 
Indigestion, chronic intestinal, 276 
Infancy and childhood, 1 
Infant, foods, 182 
mortality, 14 
stools, 237 
Infantile atrophy, 321 
spinal paralysis, 76S 
Infarction, uric acid in kidneys, 878, 

880 
Infectious diseases, 445 

table of, 448, 449 
Inflamed gums, 6 

source of invasion of tubercle ba- 
cilli, 485 
Inflammation of the dura mater, 794 
Inflammatorv rheumatism (see also 

Rheumatism), 698 
Inflation, of bowel, in intussusception, 
288 
of lungs, 47 

of stomach, in gastroptosis, 233 
Influenza, 395 

bacteriology of, 395 
complications of, 400 
diagnosis, 396 
isolation, 400 
symptoms 396 
types 396 
treatment 400 
gastric type, 398 



59 



930 



INDEX. 



Influenza, meningeal type, 398 

pulmonary type, 396 
Inhalations, in asthma, 429 
in bronchitis, 427 
in croup, 419 
Injections (see Rectal Injections), 
of horse serum, 33, 42 
intralaryngeal, 419 
intravenous, 536 

in erysipelas, 661 
subcutaneous, in scarlet fever, 627, 
632 
Insolation, 246 

differential diagnosis from menin- 
gitis, 246 
Insomnia (see Restlessness at Night), 
from use of coffee, 202 
in cretinism, 724 
in gastroptosis, 232 
in hysteria, 750 
Intermittent fever (see also Malarial 

Fever), 662 
Interstitial hepatitis, 350 
Intertrigo eczema, 829 
Intestinal colic, 273 
haemorrhage, 42, 650 
indigestion, 273 

chronic, 276 
obstruction, from intussusception, 284 

in constipation, 267 
perforation, in typhoid, 649, 653 
Intestines, 72 

abnormalities of, 267 
caecum, 73 
course of colon, 73 
sigmoid flexure, 73 
transverse colon, 73 
vermiform appendix, 73 
absorption of fat in, 74 
bacteria of, 243 
formation of gas in, 74 
haemorrhages from, 653, 731 
perforation of, 753 
Intoxication, food, 256 
Intracranial injections, 792 
Intraspinal anaesthesia, 892 

injections, 792 
Intravenous injections, 536 

in erysipelas, 661 
Intraventricular method of serum in- 
jections, 788 
Intubation, 542 

false passage in, 553, 571 
in aphonia spastica, 554 
in cicatricial stenosis, 553 

due to syphilis or traumatism, 553 
in deformities of larynx, 554 
in diphtheria, 542 
accidents during, 553 
after-effects of, 563 
effect of, in upper air passages, 560 
false passage in, 571 
feeding in, 556 

Casselberry method, 556, 557 
indications for, 544 



Intubation, in diphtheria, method of, 
547 
mortality, 544 

in papilloma of larynx, 554 
Intubation instruments, 545 

specially constructed rubber tubes, 
545, 554 
Intussusception, 285 

colic, 285 

ileo-colic, 285 

ileo or jejunal, 285 
Invagination of bowel (see also Intus- 
susception), 284 
Invertin, function of, 67, 135 
Iodophile reaction of blood, 686 
Iritis, in meningitis, 786 
Irrigation (see Rectal Irrigation). 
Irrigation, chamomile, in dysentery, 352 

cold-water, in constipation, 269 

in vaginitis, 618 

nasal, 631 

of bladder, 387 

of colon, in typhoid, 629 

saline, in diarrhoea, 245 
Ischio-rectal abscess, 295 
Isolation, in diphtheria, 529, 542 

in influenza, 448 

in measles, 596 

in mumps, 718 

in pertussis, 355 

in scarlet fever, 623 

in syphilis, 681 

in varicella, 336 

in variola, 642 
Itching, in scabies, 841 

in scarlet fever, 623 

in variola, 642 

Jacket, pneumonia, 434, 435 

James's apparatus for expanding the 

lung, 443 
Jaundice (see also Icterus), 52, 346 

catarrhal, 228 
Jaw, in alveolar abscess, 216 
in angina Ludovici, 216 
in tetanus, 758 
necrosis of, in stomatitis gangraenosa, 

211 
upper, in syphilis, 676 
Joints, diseases of, 848 

in gonorrhoea! infection, 368 
in haemophilia, 710 
in meningitis, 786 
in purpura rheumatica, 706 
in rheumatism, 699 
scrofulous, 486 
Junket, 871 
Just's food, 191 

Keller's malt soup, 166, 870 

Kenyon's syphon drainage in empyema, 

442 
Keratitis, in measles, 595 

in meningitis, 786 
Kernig's sign, 786 



INDEX. 



931 



Kidney, calculi in, 386 
congenital cyst of, 62 
dilatation of, 377 
diseases of, 370 
haemorrhage from, 3S2 
inflammation of, 371 
in new-born, 878 
in pyelitis, 378 
in scarlet fever, 614, 620 
position of, in infancy, 370 
sacculation of, 377 
Klebs-Loeffler bacillus, 502, 503 
in diphtheritic omphalitis, 35 
in measles, 592 

in membranous conjunctivitis, 821 
smear preparation, 505 
stain for, 889 
Knee, in morbus coxarius, 861 

in rachitis, 316 
Knee-jerk (see Patellar Reflexes). 

in multiple neuritis, 752 
Knee-joint disease, 85 

differential diagnosis from rheu- 
matism, 864 
in morbus coxarius, 861 
in rachitis, 316 
Knock-knee, in rachitis, 316 
Koplik's sign in measles, 587 
Kyphosis, 855 

in Pott's disease, 848 
in rachitis, 314 

Lab ferment, 65 

action of, on milk, 76, 77 
Laboratory modification of milk (see 

also Percentage Feeding), 170 
Lachrymal duct, inflammation of, in 

nasal catarrh, 391 
Lactation, massage of breasts during, 94 
Lactic acid, in buttermilk, 174 

in gastric contents, 875 

in stomach, 66 

in urine, 174 
Lactic acid bacillus, 174 
Lactoscope, 134 
Lactose, 136 

La grippe (see Influenza), 395 
Lahmann's vegetable milk, 178 
Laparotomv, in intestinal perforation, 
653' 
in intussusception, 288 
in tuberculous peritonitis, 358, 360 
Laryngeal spasm, 756 

m bronchial asthma, 428 

in rachitis, 312 

in status lymphaticus, 711 

recurring, 561 
Laryngeal stenosis, congenital, 60 

in diphtheria, 512, 537, 542 

in retropharyngeal abscess, 416 

intubation, in chronic, 554 

specific, following intubation, 569 
Laryngitis, complicating measles, 592 
spasmodic, 417 



Laryngitis, diagnosis from diphtheritic 
croup, 417 
predisposing factors, 418 
treatment, 419 
Larynx, congenital stenosis of, 60 

foreign bodies in, 420 

granulomata of, 847 

growths of (see also Papillomata), 
846 

in diphtheria, 512, 545 

intubation in, 555 

tolerance of, for intubation tube, 554 

tracheotomy, in stenosis of, 574 
Late speaking, 3 

Lateral curvature of the spine, 855 
Lavage (see Stomach-washing). 
Lecithin, 199 

Leeches, application of, to relieve cere- 
bral congestions, 475 

in convulsions, 741 

in orchitis, complicating mumps, 717 

in rheumatism, 702 
Leffert's "nasal syringe, 393 
Lentigo, 834 

Leptomeningitis (see also Pachymenin- 
gitis), 794 
Leucocytosis, 684 

in appendicitis, 281 

in chorea, 687 

in diphtheria, 508 

in influenza, 396 

in nervous diseases, 687 

in pneumonia, 467 

in rachitis, 686 

in scarlet fever, 604 
Leucomain poisoning, 708 
Leucopsenia in typhoid, 652 
Leukaemia, 693 

blood in, 693, 694 

lymphatic form, 693 

myelogenous form, 693 

splenic form, 693 
Lichen tropicus, 833 

Liebermann phenol test for formalde- 
hyde in milk, 122 
Lien mobilis, 352 
Lime, saccharated solution of, 143 

water, in modification of milk, 143 
Lingual tonsil, in status llymphaticus, 711 
Lipoma, 846 

Lips, cvanosis of,, in broncho-pneumonia, 
431 

in adenoid vegetations, 411 

in cretinism, 719 

in septic diphtheria, 513 
Liquor potassse test for pus in urine, 886 
Lisping, 744 
Lithsemia, 708 

diet in, 709 

urine in, 709 
Lithuria (see also Lithaemia), 708 
Liver, abscess of, 347 

amyloid degeneration of (waxy), 349 

cirrhosis of, 350, 691 

descended, 349 



932 



INDEX. 



Liver, diseases of, 346 

displacement of, 348, 349 

in constipation, 268 
fatty, 349 

focal necrosis of, 350 
functional disorders of, 348 
in congenital obliteration of the bile- 
ducts, 37 
in diphtheria, 59, 515 
in faulty metabolism, 298 
in gastro-duodenitis, 228 
in leukaemia, 693, 694 
in malarial fever, 667 
in pseudo-leukaemic anaemia, 695 
in scarlet fever, 619 
in tuberculosis, 493 
spots (see also Chloasma), 832 
weight of, 346 
Lobar pneumonia, 460 
Lobular pneumonia, 429 
Local anaesthesia, 891 

by injection of sterile water, 892 
blood letting, 897 
remedies, 896 
Lock-jaw (see also Tetanus), 758 
Loeffler's bacillus, 504 
Loefflund's malt soup, 160 
Lordotic albuminuria, 381 
Loss of speech due to paralysis, 4 
Luetin reaction, 678 
Lumbar puncture, 783, 789 

amount of fluid to be withdrawn, 

790 
needle required, 789 
place for puncture, 789 
dry- tap in, 790 
in convulsions, 741 
in hydrocephalus, 777 
in meningitis, tubercular, 782 
epidemic cerebro-spinal, 789 
infantile spinal, 774 
Lung, at term, 1 
inflation of, 47 
auscultation of, 423 
cavities of, 479 
compressed, 431 
cut surface of, 479 
gangrenous infiltration of, 211 
in broncho-pneumonia, 432 
in diphtheria, 610 
in empyema, 440, 443 
in lobar pneumonia, 460, 461 
in tuberculosis, 424 
in wandering pneumonia, 464 
percussion of, 424 

points in examination of, 423 
transverse section of, 480 
Lymphadenitis, retropharyngeal, 415 
Lymphatic glands (Lymph Nodes), dis 
eases of, 711 
enlarged, causing torticollis, 705 
in anaesthesia, 891 
in diphtheria, 508 

local, 512 
in leukaemia, 693 



Lymphatic glands, in mumps, 717 

in pseudo-leukaemic anaemia, 695 
in retro-cesophageal abscess, 217 
in retro-pharyngeal abscess, 415 
in tonsillitis, 405 
in tuberculosis, 493 
Lymphocytes, increase of, after second 
year, 684 
in diphtheria, 687 
in malaria, 687 
in pneumonia, 687 
in scarlet fever, 687 
in typhoid, 687 

MacEwen's percussion note, 733 
Macrocephalus, in epilepsy, 760 
Macrocytes, in syphilis, 685 
Mackenzie tonsillotome, 409 
Magendie foramen, in hydrocephalus, 

736 
Malarial fever, 662 
blood in, 667 
Plasmodia in, 663 
symptoms, 670 
treatment, 671 
aestivo-autumnal, 665 
double tertian, 662 
quartan, 664 
quotidian, 662 
tertian, 662 
Malformations of the rectum, 63 

of the spinal cord, 766 
Malignant, endocarditis, 338 
growths, 842 

in bladder, 387 
purpuric fever, 784 
Malt extract, in summer complaint, 167 
soup, 166 
to make, 160 
Malted milk, Horlick's, 184 
Maltose, 67 

Mammala, infant food, 190 
Mammary glands, 54, 79 
Mannaberg's table of malarial parasites, 

669 
Marasmic thrombosis, 818 
Marasmus, 321 

Marchand's test for fat in milk, 134 
Massage, method of performing, 272 
in cerebral paralysis, 800 
in constipation, 271 
in spinal paralysis, 772 
of breasts during lactation, 94 
vibratory, 271 
Mastitis neonatorum, 54, 
Mastoid disease, in otitis media, 815 
operation for, 815 
facial paralysis following, 817 
Masturbation, 754 

treatment, 755 
Maternal feeding, 85 
Matzoon (see also Zoolak), 198 
Measles, 584 

bacteriology, 584 
complications, 591 



INDEX. 



933 



Measles, diagnosis, 596 

from drug eruption, 596 
from influenza, 596 
from variola, 641 
immunity, 595 
incubation period, 580 
mortality, 584 
sequelae, tuberculosis, 486 
symptoms," 585 

desquamation, 588 
enanthem, 585 
eruption, 587, 588 
treatment, 596 
isolation, 596 
German, 577 

hemorrhagic form, 590 
malignant form, 589 
mild form, 589 
relapsing form, 589 
Meat juice, 200 
Meckel's diverticulum, 37 
Meconium, 237 

Medication, points concerning, 895 
hypodermic, 908, 909 
local, S96 
rectal, 898 
Megacolon, 272 
Meig's food, 198 
Melsena, 41 
Mellin's food, 189 

Membrane, in diphtheria, 502, 512 
Membranous conjunctivitis, 821 
Meningitis, cerebro-spinal, 784 
bacteriology, 784 
complicating diphtheria, 524 
diagnosis, 787 
etiology, 784 
lumbar puncture in, 786 
mortality, 785 
pathology, 784 
prognosis, 791 
symptoms, 785 

Brudzinski's neck sign, 786 
Kernig's sign, 786 
treatment, 791 

serum, 792 
tubercular, 779 
bacteriology 
course, 7S1 
diagnosis, 782 
etiology, 779 
lumbar puncture in, 783 
pathology, 779 
symptoms, 782 

Babinski reflex, 783 
tache cerebrale, 783 
treatment, 783 
Meningocele, 177 
Meningococcus, 784 

stain for, 889 
Menstruation, effect of, on woman's 
milk, 75, 79, 99 
in chlorosis, 696 
prsecox, 369 
vicarious, 368 



Mental faculties, 2 

Mercurv, administration of,- to children, 
211, 899 
in treatment of syphilis, 681 
Meteorismus (see also Intestinal Colic), 

273 
Microcephalus, craniectomy in, 800 
fontanel in, 729, 776 
in chronic hydrocephalus, 776 
in epilepsy, 760 
Micrococcus catarrhalis, 784, 787 

in nasal catarrh, 391 
Microcytes, in syphilis, 685 
Micro-organisms (see Bacteria). 
Middle-ear abscess, causing abscess of 

brain, 804 
Migraine, 743 
Miliaria papulosa, 833 

rubra, 834 
Miliarv tuberculosis, 483 
Milk, albumin, 140 
Bulgarian, 174 
cows', 114 

addition of. alkalies to, 143 
adulteration of, 119 

formaldehyde in, 120 
albuminoids in, 13S 
analvsis of, 114, 115 
certified, in New York City, 118 
composition of, 114 
condensed, 179 
diluents of, 149 
eiweiss, 140 
enzvmes in, 145 
fat," 132 

home modification of, 150 
idiosyncrasy, 169 
infection, 256 
pasteurization of, 156 
predigested or peptonized, 873 
protein in, 137 
raw, 128, 129 
salts in, 141 

skimmed in feeding of premature in- 
fants, 33 
starch in, 145 
sterilization of, 152 

changes caused by, 153 
tuberculous infection through, 122, 

131 
undiluted, as a food for infants, 131 
variations of, 114 
vitamines in, 145 
woman's (see also Breast Milk), 75 
analysis of, 7S 

comparative, 80, 83 
apparatus for examination of, 79, 

81 
colostrum in, 74 
composition of, 78 
deterioration of, 104 
examination of, microscopical, 81 
enzymes, diastatic in, 82 
fat in, to decrease, 104 
to increase, 104 



934 



INDEX. 



Milk, woman's, immunity conferred by, 
82, 483, 530 
method of changing ingredients in, 

104 
to increase quantity of, 88, 96 
to preserve, 83 
proteins in, 104 
reaction of, 82 
scanty, 87 

specific gravity of, 79 
specimen for examination, 80 

how to procure, 80 
variations in, 101 
Milk substitutes, cereal, 185 
humanized, 192 
Lahmann's vegetable, 178 
mammala, 190 
Milk-sugar or lactose, 136 
Milk-test, Babcock's, 133 
Mineral salts in milk, 141 
Mixed feeding, 87, 107 

additional foods during the nursing 
period, 91 
Mobius'sche kernschwund (see also Pleu- 

roplegia), 800 
Modified small-pox (see also Varioloid), 

642 
Monarthritis, 368 

in gonorrhceal vaginitis, 368 
Mongolian idiocy,. 807 
Monoplegia, 736 

Morbilli (see also Measles), 584 
Morbus coxarius, 861 
Morbus maculosus Werlhofii, 706 
Mortality, in cerebro-spinal meningitis, 
784 
in consumption, 492 
in diphtheria, 503 
in measles and complications, 590 
in small-pox, 638 
of babies raised in incubators, 28 
Morton's fluid, 778 
Mosite in diabetes insipidus, 383 
Mosquera's beef meal, 195 

beef jelly, 196 
Motor function of the stomach, 876 
Mouth breathing, a symptom of ade- 
noids, 411, 412 
of enlarged tonsils, 408 
Mouth, condylomata of, in syphilis, 676 
diseases of, 205 

haemorrhage from, in syphilis, 675 
hygiene of, 17 
in adenoid vegetations, 411 
in angina Ludovici, 216 
in Bednar's aphthae, 208 
in stomatitis aphthosa, 207 
in stomatitis catarrhalis, 206 
in stomatitis mycosa, 208 
Movable spleen, 352 

Mucous membrane, conjunctival, in gas- 
tro-duodenitis, 228 
of mouth, at birth, 65 

in measles, 586 
of pharynx, in scarlet fever, 608 



Mucous membrane, of stomach, 65 
in gastric catarrh, 219 
of trachea and bronchi, in broncho- 
pneumonia, 430 
Mucus disease, 276 

in stools, 242 
Muguet (see also Stomatitis Mycosa), 

208 
Multiple neuritis, 751 

treatment, 753 
Mumps, 716 

complications, 717 
diagnosis, 717 
isolation, 718 
period of incubation, 716 
symptoms, 716 
treatment, 717 
Murmurs, 330 
anaemic, 331 
cardiac, 328, 330 
cerebral blowing, 333 
Murmurs, diastolic, 331 
pericardial, 332 
systolic, 330 

in chlorosis, 696 
venous, 332 

in chlorosis, 696 
vesicular, in bronchial asthma, 428 
Muscle education, 812 
Muscles, atrophy of, in acute myelitis, 
764 
in poliomyelitis, 770 
transplantation of, 774 
fatty infiltration of, in pseudo-hyper- 
trophic paralysis, 801 
intestinal, 74 

wasting of, in scurvy, 306 
Muscular atrophy, in acute myelitis, 764 
in poliomyelitis, 770, 774 
in pseudo-hypertrophic paralysis, 
801 
rheumatism, 703 
spasms, in rachitis, 312 
Mustard foot bath, 597 

in convulsions, 741 
plasters, 897 
Myalgia, 703 
Myelitis, acute, 764 

chronic, 766 
Myelocytes, 685 
in diphtheria, 685 
in leukaemia, 694 
in pneumonia, 685 
in syphilis, 685 
Myocarditis, 343 

complicating diphtheria, 523 
treatment, 344 
Myxoedema (see also Cretinism), 719 
Myxcedematous idiocy, 719 

Naevus, 836 

Nails, in secondary anaemia, 692 

in syphilis, 675 
Nasal catarrh, 391 

a symptom of measles, 390 



INDEX. 



935 



Nasal catarrh, a symptom of syphilis, 
675 
causing otitis, 391 
diphtheria, 513 
douching, 394, 627 
syringe, 393 
Naso-pharyngeal catarrh, 394 

in syphilis, 675 
Navel, dangers in handling, 35 

management of, 17 
Necrosis of liver, in malarial fever, 666 
of jaw-bone, following stomatitis 
gangrenosa, 211 
Neck, in cretinism, 719 

rigidity of, in typhoid, 650 
stiff, in torticollis, 704 
Neonatorum (see New-born Infant), 
hemoglobinuria, 40 
icterus, 52 

urine in, 878 
mastitis, 54 
ophthalmia, 821 
pemphigus, 56 
sclerema, 53 
Neo-salvarsan in treatment of noma, 214 
in treatment of scarlet fever, 632 
ulcero-membranous tonsillitis, 406 
Nephritis, acute, 370 

as a complication, 372 

blood in, 371 

complicating diphtheria, 525 

influenza, 400 
urine in, 371, 372, 879 
acute glomerulo-, 370 
catarrhal, in scarlet fever, 614, 620 
chronic interstitial, from increased 

urinary pressure, 377 
post-scarlatinal, 615, 620 
secondary, 373 
Nerve, pneumogastric, in dyspeptic 

asthma, 236 
Nerves, in multiple neuritis, 751 

vasomotor, causing asthmatic attacks, 
428 
Nervous impressions, effect of, on 

woman's milk, 88 
Nervous system, diseases of, 733 
hygiene of, 23 
in typhoid, 650 
Nestle's food, 183 

analysis of, 184 
Nettle rash (see also Urticaria), 830 
Neuralgia, interstitial, 273 

complicating variola, 642 
Neuritis, multiple, 751 

complicating influenza, 399 
treatment, 753 
peripheral, 751 
New-born, abnormalities of, 57 
acute fatty degeneration of, 41 
asphyxia of, 45 
bleeding in, 676 
Buhl's disease, 41 
diphtheria in, 35 
erysipelas in, 55 



Newborn, fracture in, 43 

hsemoglobinuria in, 40 

haemorrhage, gastro-intestinal, in, 40 
into adrenal glands, 732 
umbilical, 35, 40 

ichthyosis of, 50 

icterus of, 53 

inflation of the lungs in, 47 * 

malformations of, 57 

mastitis in, 54 

paralysis of, 43, 802 

pemphigus in, 56 

peritonitis in, 55 

sclerema in, 53 

syphilis in, 672 

tuberculosis in, 55, 673 

typhoid in, 647 
Night cough, 421 

Night-sweats, in tuberculosis, 498 
Night-terrors (see also Pavor Noctur- 

nus), 753 
Nipple, anticolic, 151, 153 

harelip, 58 

management of woman's, 92 

sterilizer, 153 
Nipple-shield, 93 
Nitrous oxide and ether, 890 
Nodding-spasm, 743 
Nodes, lymph (see Lymph Nodes). 
Nodules, subcutaneous tendinous, in 
rheumatism, 700 

tubercular, 779, 780 
Noguchi's butyric-acid test for syphilis, 

673 
Noma (see also Stomatitis Gangrenosa), 
210 

in scarlet fever, 632 
Nose, discharge from, in diphtheria, 
512 

diseases of, 391 

foreign bodies in, 402 

hemorrhage from, in exophthalmic 
goiter, 731 
in syphilis, 675 

in adenoid vegetations, 411 

in cretinism, 719 

picking of, 290 
Nose-bleed (see also Epistaxis), in 
diphtheria, 524 

in syphilis, 675 
Novocaine as local anesthetic, 892 
Nurse (see also Wet-nurse), 22 
Nursery, furniture in, 22 

light of, 22 

location of, 21 

method of heating, 22 

ventilation, 21 
Nursing (see also Feeding), 84 

length of time for, 87 

schedule for, 84 
Nursing bottles, 150 

care of, 151 
Nutrient enemata (see Rectal Feeding). 
Nutrients and stimulants, 198 
Nutrition, 65 



936 



INDEX. 



Nutrition, improper, 298 

Nutritional disturbance, 168 

Nutritive tonics, chemical analysis of, 

197 
Nutritive value of eggs, 199 
Nylander's test for sugar in urine, 885 
Nystagmus, complicating spasmus nu- 
tans, 743 
in hereditary ataxy, 767 

Oatmeal bath, 19 
in eczema, 828 

water, 869 
Obliteration of the bile-ducts, congeni- 
tal, 37 
Obstetrical paralysis, 43 
Obstipation, 299 

O'Dwyer's method of intubation, 547 
CEdema in angina Ludovici, 216 
in erysipelas, 660 
in variola, 624 

of ankle, 696 

of cheek, in stomatitis gangrenosa, 211 

of eyelids, in thrombosis of cerebral 
sinuses, 818 

of feet, in myelitis, 765 

of glottis, in scarlet fever, 631 

of larynx, 617 

of lips, in myelitis, 765 

of pia mater, 617 

of scalp, 818 
Oesophagitis, acute, 217 

chronic or diphtheritic, 217 
Oesophagus, foreign bodies in, 218 
O^gophony, 438, 440 
Oil, enema, in acute peritonitis, 355 

internally in chronic constipation, 269 
Oiled-silk jacket (see also Pneumonia 
Jacket), 477 
how to make, 435 
Omphalitis, diphtheritic, 35, 512 

septic, 36 
Omphalomesenteric duct, 36 
Onanism (see also Masturbation), 754 
Ophthalmia, granular, 822 

neonatorum, 821 

pneumococcus, 820 

purulent, 821 
Ophthalmo-tuberculin reaction, 496 
Opisthotonos, hysterical, 749 

in meningitis, 786 
Orchitis, 366 

in mumps, 717 
Orthostatic albuminuria, 381 
Osteitis, infectious, 866 

of the femur, 864 

of the tibia, 864 
Osteoclasis in rachitis, 320 
Osteomyelitis (see also Arthritis, Acute), 

866 
Osteotomy in rachitis, 320 
Otitis, complicating diphtheria, 523 

complicating influenza, 400 

complicating measles, 594 

complicating rhinitis, 391 



Otitis, complicating scarlet fever, 610, 
624 
complicating typhoid, 654 
complicating variola, 642 
Otitis media,, acute catarrhal, 812 
symptoms, 813 
treatment, 814 
Oxygen, in dyspnoea and cyanosis, 476 
in pulmonary stenosis, 334 
in resuscitation, 48 
Oxyuris vermicularis, 292 
Ozsena, a sequela to scarlet fever, 622 
Ozonic ether test for pus in urine, 886 

Pachymeningitis, acute, 794 
chronic, 794 
hemorrhagic, 794 
non-hsemorrhagic, 794 
Pack, cold, 518 

hot, 626 
Palate, cleft, 58 

in Bednar's aphthae, 208 
in measles, 585 
in purpura hemorrhagica, 706 
in rubella, 578 

paralysis of, in diphtheria, 526 
Palpation of the liver, 346 

of the spleen, 352 
Palsy, Erb's (see also Paralysis), 774 

acute spinal, from acute cerebral, 770 
Paludal fever (see also Malarial Fever), 

662 
Pancreas, diseases of, 353 
function of, 353 
in syphilis, 675 
position of, 353 
Pancreatic juice, 65 
Panopepton, 196 

Panophthalmitis, in meningitis, 786 
Papillomata, 847 
Paracentesis, in otitis, 628 
Paralysis, following pertussis, 457 
in hereditary ataxy, 767 
in multiple neuritis, 752 
in Pott's disease, 851 
in thrombosis of cerebral sinuses, 

818 
of vocal cords, following intubation, 
567 
Bell's, 802 
cerebral, 795 

acquired after labor, 796 
diagnosis, 797 

differential, from infantile spinal, 
799 
occurring during labor, 796 
of intra-uterine onset, 796 
facial, 802 

following mastoid operation, 817 

retro-pharyngeal abscess, 817 
in the new-born, 802 
infantile spinal, 768 
diagnosis, 770 

from cerebral paralysis, 799 
micro-organism causing, 768 



INDEX. 



937 



Paralysis, infantile, pathology, 769 
symptoms, 770 

preparalytic, 770 
treatment, 772 

muscle education, 772 
post-diphtheritic, 525, 540 
frequency of, 526 
of bladder, 526 
of extremities, 527 
of palate, 526 
of rectum, 526 
of trunk, 526 
Paraphimosis, 364 

Paraplegia (see also Paralysis, Cere- 
bral), 795 
Parasitic stomatitis (see also Stomatitis 

Mycosa), 208 
Parotitis, specific (see also Mumps), 716 
Pasteurization of cows' milk, 157, 872 
Patellar reflexes, in cerebral paralysis, 
797 
in diphtheria, 514 
in meningitis, 786 
in pseudohypertrophic paralysis, 802 
Patent foods, 181 
Pavor nocturnus, 753 
Pediculosis, 833 
Peliosis rheumatica, 706 
Pellagra, 255 
Pelvis, in congenital dislocation of hips, 

863 
Pemphigus, chronic, 836 
Pemphigus, in syphilis, 675 

neonatorum, 56 
Pendulous belly, in rachitis, 316 
Pepsin, 65 

function of, 66, 67 
in gastric contents, 876 
Peptogenic milk powder, 192 
Peptone, in gastric contents, 876 
Peptonized milk, 873 
Percentage feeding, 170 
Percussion, of the lungs, 424 
of the skull, 733 
resonance, 424 
Pericardial murmurs, 332 
Pericarditis, 339 

complicating diphtheria, 523 
complicating rheumatism, 654 
complicating typhoid, 701 
chronic, with adhesions, 342 
Pericardium, aspiration of, 341 

tuberculosis of, 342 
Perinephritis, 374 

diagnosis from hip-joint disease, 375 
simulating Pott's disease, 375 
simulating sciatica, 375 
Perineum, in imperforate anus, 63 
Periostitis, complicating stomatitis gan- 
grenosa, 211 
in syphilis, 677 
Peripheral neuritis (see also Multiple 

Neuritis), 751 
Peritoneum, diseases of, 354 
Peritonitis, acute, 354 



Peritonitis, acute, ascites due to, 359 
complicating rheumatism, 700 
complicating typhoid, 654 
chronic, 355 
fibrinous, 354 
in the new-born, 55 
non-tuberculous, 355 
purulent, 354 
serous, 354 
tuberculous, 356 
Peritonsillar abscess, 406 

resembling diphtheria, 522 
Perityphlitis (see also Appendicitis), 
278 
tuberculous, 486 
Pernicious anaemia, 692 
Perspiration (see also Sweating), 12 
Pertussis, 455 

complement-deviation test, 455 
complications, 457 
diagnosis, 456 
sequela?, tuberculosis, 486 
treatment, 458 
vaccine, 452 
Petechia, in haemophilia,- 710 

in purpura, 705 
Peyer's patches, 72 
in typhoid, 646 
Pharyngeal catarrh, causing spasmodic 

croup, 417 
Pharyngitis, 415 

in influenza, 396 
Pharynx, in local diphtheria, 512 
in mycosa, 208 
in scarlet fever, 604 
in septic diphtheria, 512 
in stomatitis aphthosa, 207 
Phimosis, 363 

Phlegmonous tonsillitis, 406 
Phloroglucin test for formaldehyde in 

milk, 119 
Phlyctenular conjunctivitis, 826 
Phosphorus, 141 

in rachitis, 319 
Photophobia, in cerebro-spinal menin- 
gitis, 786 
in measles, 585 
Phthisis (see also Pulmonary Tuber- 
culosis), 498 
pulmonis, mortality in, 491 
Physical examination, of heart, 327 

. of lungs, 423 
Physical exercise, 22 

signs, in empyema, 440 

in lobar pneumonia, 426, 466, 472 
in pleurisy with effusion, 438 
Pia mater, blood-vessels of, 736 

closure of, in hydrocephalus, 736 
in tubercular meningitis, 779 
Pigeon-breast (see also Prominent Ster- 
num), 61 
in rachitis, 310, 312 
Pigmentary nsevus, 736 
Pink eye, 820 



938 



INDEX. 



Pinworms, 292 
Plasmodium malaria, 662 
Plasmon, 195 
Pleura, diseases of, 423 
effusion into, 438 
swollen, in dry pleurisy, 436 
Pleurisy, 435 

complicating diphtheria, 435 
complicating rheumatism, 700 
dry, 436 
purulent, 439 
with effusion, 437 
diagnosis, 438 

exploratory puncture, 438 
symptoms, 438 
treatment, 438 
Pleuritis, exudativa, 437 
Pleurodynia, 703 
Pleuroplegia, 800 
Pleuropneumonia, 464 
Pleurothotonus, in pericarditis, 340 
Pneumococcus, in broncho-pneumonia, 
430 
in empyema, 440 
in follicular tonsillitis, 405 
in measles, 594 
in meningitis, 784 
in perinephritis, 374 
in pleurisy with effusion, 437 
ophthalmia, 820 

vaccine treatment, 453 
Pneumo-gastric disturbance, causing 

asthmatic attacks, 236, 428 
Pneumonia (see Broncho-pneumonia), 
abortive, 462 
catarrhal, 464 
cerebral, 464 
croupous, 460 
gastric, 464 
lobar, 460 

bacteriology, 462 
course, 465 
crisis, 467 
diagnosis, 472 
etiology, 460 
isolation, 472 
pathology, 462 
relapse, 472 
symptoms, 465 
treatment, 473 
vaccine, 454 
migrans, 464 
pleuro-, 464 
tuberculous, .477, 479 
wandering, 464 
Pneumonia jacket, 434 
Pneumothorax, artificial, 444 
Pock in varicella, 633 
Poikilocytosis, in syphilis, 685 
Poisons (see Toxins). 

causing toxic multiple neuritis, 752 
elimination of, 245 
Poliomyelitis (see also Paralysis, In- 
fantile Spinal), 768 



Poliomyelitis acute anterior, from post- 
diphtheritic paralysis, 527 
Polyarthritis (see also Rheumatism), 

698 
Polydipsia (see Thirst, Excessive). 
Polymorphonuclear cells, in ervsipelas, 
684 
in diphtheria, 684 
in pneumonia, 684 
in scarlet fever, 684 
Polyneuritis (see also Multiple Neu- 
ritis), 751 
Polynuclear leucocytes, increase of, in 
pus, 281 
in infectious diseases, 684 
Polypus, recta], 689 

umbilical, 36 
Polyuria, 383 

in diabetes mellitus, 384 
Porencephaly, 778 
Potassium salts in milk, 142 
Post-diphtheritic paralysis, 526 
Post-operative palsy (see also Facial 

Paralysis), 802 
Pot-belly in rachitis (see also Pendu- 
lous Belly), 316 
Pott's disease, 848 
complications 851 
differential diagnosis from rickets, 

321 
pathology, 849 
symptoms, 850 
treatment, 854 
Poultices, flaxseed, in retro-pharyngeal 
abscess, 416 
in tonsillitis, 404 
how to make, 896 
ginger, 897 
Powder, dusting, 18, 635 
Precordia, prominence of, 328 
Predigested milk, 873 
Pregnancy, effect of, on nursing in- 
fants, 32 
Premature infants, 26 

method of feeding, 30 
Prepuce, adherent, 363 

tight, causing enuresis, 389 
masturbation, 754 
Prescriptions for various diseases, 900 
Pretubercular ansemia, 493 
Priapism, in phimosis, 363 
Prickly heat, 833 
Procrisis, in pneumonia, 467 
Proctitis, croupous, 295 
simple, catarrhal, 294 
ulcerative, 295 
Prognosis, in disease, 14 
Prolapse of rectum, 296 

in diseases of the bladder, 379, 386 
of the intestines, 262 
Prominent sternum, 61 
Propeptone in gastric contents, 876 
Prophylaxis in diphtheria, 528 
Proprietary infant foods, 181 
Protein, function of, in diet, 137 



INDEX. 



939 



Protein in cows' milk, 138 

in excess, causing colic, 274 
in woman's milk, 103, 138 
to increase, 104 
Protrusion of ears, 60 
Pseudo-appendicitis, 282 
Pseudo-diphtheria, 500 
Pseudo-hypertrophic paralysis, 801 
Pseudo-leuksemic anaemia, 694 
blood in, 695 
spleen in, 695 
Pseudo-paralysis, in scurvy, 303 

in syphilis, 680 
Pseudo-pertussis, 422 
Psoriasis, 832 
Ptosis in thrombosis of cerebral sinuses, 

818 
Ptyalin, function of, 67 
Pulmonary artery, thrombosis of, in 
diphtheria, 524 
gangrene, 4S2 
gymnastics, 498 
in empyema, 443 
in tuberculosis, 49S 
stenosis, 333 
tuberculosis, 479 
Pulmotor, Drager, 48 
Pulse, in diagnosis, 10, 330 
Pulsus paradoxus, 330 
Pump, breast, 93, 94 
Pupils, as diagnostic aid, 12 

in cerebro-spinal meningitis, 786 
in chorea, 746 
in insolation, 246 
in myelitis, 764 
in pachymeningitis, 794 
Purpura, 405 

complicating rheumatism, 700 
diagnosis from scurvy, 706 
hemorrhagica, 706 
rheumatica, 706 
Purulent ophthalmia, 868 
pleurisy, 439 
synovitis, acute, 866 
Pus corpuscles in urine from case of 
scarlatinal nephritis, 616 
tests for, in urine, 886 
Pysemia, complicating measles, 595 
typhoid, 654 
in acute nephritis, 866 
Pyelitis, 376 

in gonorrhoeal infection, 368 
Pyelo-nephritis (see also Pyelitis), 376 
Pyloric obstruction, 224 
diagnostic aid, 224 
symptoms, 224 
Pvlorus, spasm of, 224 
Pyuria, 381 

in colicystitis. 3S6 
in pyelitis, 377 

Quartan intermittent fever, 664 
Quincke's lumbar puncture, 787 
Quinsy, 406 
Quotidian intermittent fever, 663 



Rabies, vaccine treatment, 453 
Rachitis, 307 
causes, 311 

lack of vitamines, 144 
deformities, 319 
diagnosis, 316 

differential, from Pott's disease, 321 
diet in, 318 

laryngeal stenosis in, 563 
prognosis, 317 
svmptoms, 311 
treatment, 318 
of kyphosis, 319 
Ranula, 215 

Rashes (see Eruptions). 
Raw milk, 128, 129, 131 
Raynaud's disease, 841 
Reaction of degeneration, 737 
in acute myelitis, 764 
in acute poliomyelitis, 770 
in multiple neuritis, 752 
in obstetrical paralysis, 44 
Rectal, feeding in bronchitis, 427 

in cerebro-spinal meningitis, 783 
injections (see Enemata and Irriga- 
tions), 
polypi 297 
Rectum, congenital absence of, 64 
diseases of, 294 
imperforate, 63 
malformations of, 63 
protrusion of, 296 
stimulation by, 476 
Red gum (see also Miliaria Rubra), 

843 
Reflex cough, 422 
Reflexes, in acute myelitis, 764 
in cerebral paralysis, 797 
in spinal paralysis, 770 
patellar, in cerebro-spinal meningitis, 
786 
in diphtheria, 514 
in hereditary ataxy, 768 
in pachymeningitis, 795 
Regurgitation, of food in pyloric ob- 
struction, 224 
nasal, 416, 522, 526 
Remittent fever (see also Malarial 

Fever), 662 
Rennet, action of milk on, 139 

test for, in gastric contents, 876 
Resection of ribs, 442 
Resonance, percussion, 424 

vocal, 424 
Respirations (see Breathing), 
artificial, 46 
asleep, 11 
awake, 11 

Cheyne-Stokes, in tuberculous pneu- 
monia, 478 
in bronchial asthma, 428 
in bronchitis, 426 
in broncho-pneumonia, 431 
in infancy, 431 
in lobar pneumonia, 466 



940 



INDEX. 



Respirations, in tubercular meningitis, 
786 
wheezing, 428 
Respiratory system, diseases of, 391 
Rest treatment in chorea, 747 
Restlessness at night, a symptom of 
worms, 291 
in constipation, 268 ' 
in faulty metabolism, 299 
in gastroptosis, 232 
in rachitis, 317 
Resuscitation of the new-born, 46 
by pulmotor, 48 
Byrd's method, 46 
Retraction of head, in cerebro-spinal 
meningitis, 786 
in epilepsy, 761 
in influenza, 396 
Retro-cesophageal, abscess, 217 
Retro-pharyngeal abscess, 416 

complicating cerebral pneumonia, 
465 
lymphadenitis, 415 
Rhagades of anus and mouth in syph- 
ilis, 675, 680 
Rheumatic torticollis, 705 
Rheumatism, acute, 698 
bacteriology, 699 
complications, 700 
symptoms, 699 

subcutaneous tendinous nodules, 
700 
treatment, 701 
articular, 700 
chorea in, 700 
following tonsillitis, 699 
muscular, 703 
purpura in, 700 
Rhinitis (see also Nasal Catarrh), 391 
Rhinolith, 402 
Rhino-pharynx, method of examining 

for adenoids, 412 
Rhythm, 424 
Ribemont's tube for inflating the lungs, 

47 
Ribs, beaded, 311, 312 

resection of, 442 
Rice water, 846 

Rickets (see also Rachitis), 307 
Rimini test for formaldehyde in milk, 

119 
Ringworm (see also Tinea Tonsurans), 
837 
x-ray treatment, 837 
Robert's test for albumin in urine, 883 
Roentgen rays as diagnostic aid, 15 
Rotary spasm of head (see also Spas- 
mus Nutans), 743 
Rotheln (see also Rubella), 577 
Round worms, 290 
Rubella, 577 

complications, 582 
desquamation, 580 
diagnosis, 578 
eruption, 579 



Rubella period of invasion, 578 

symptoms, 578 

treatment, 582 
Rubeola (see also Measles), 584 
Rupture (see Hernia). 

of spleen, in malarial fever, 666 

Sacral tumor, congenital, 62 

Saint Vitus's dance (see also Chorea), 

744 
Salicylic-sulphur paste, 829 
Saline solution, for colonic flushings, 
632 
in erysipelas, 661 
cold, in typhoid, 655 
subcutaneous injections of, 626 
Saliva, action of, on bacteria, 66 
in stomatitis gangrenosa, 210 
secretions of, at birth, 65 
Salt-free diet in scarlet fever and ne- 
phritis, 624 
Salts in milk, 141 

Sarcoma, spindle-cell, of the thorax, 842 
Scabies, 841 

Scalp, fatty growths of (see also 
Lipoma), 846 
in caput succedaneum, 62 
ringworm of, 837 
seborrhea of, 835 
Scarlatina ( see Scarlet Fever ) . 
papulosa, 607 
post-operative, 622 
sine angina, 607 
sine exanthemata, 606 
sine febre, 607 
variegata, 607 
Scarlet fever, 599 
bacteriology, 600( 
blood in, 602 
complications, 608, 611 
diagnosis, 617 

from variola, 641 
hemorrhagic, 606 
inclusion bodies in blood of, 601, 

602 
incubation stage, 600 
isolation, 618 
rash, 604, 617 
septic, 605 
symptoms, 604 
treatment, 618 

serum, 628 
vulvo-vaginitis following, 622 
Schick reaction, 520 
Schonlein's disease, 706 
Sciatica, 375 
Sclerema neonatorum, 53 
Scoliosis, 855 
Scorbutus, 301 

Scrofula (see also Tubercular Adenitis), 
714 
lesions of, 681 

resembling tuberculosis, 484 
Scurvy, 301 

caused by lack of vitamines, 144 



INDEX. 



941 



Scurvy, caused by prolonged sterilized 
milk feeding, 155 
diagnosis, 303, 306 
etiology, 301 
pathology, 302 
symptoms, 303 
treatment, 306 
Seborrhoea, 835 
Secondary anaemia, 692 
Seller's solution, 393 
Senses, development of, 2 
Sensitive skin, 19 
Septic diphtheria, 512 

nephritis, complicating scarlet fever, 

615 _ 
omphalitis, 36 
Serum injection, intravenous method of, 
788 
in gastro-intestinal haemorrhage, 42 
in premature infants, 33 
in tubercular peritonitis, 392 
test for typhoid, 648 
treatment of diphtheria, 534 
of dysentery, 266 
of erysipelas, 661 
of meningitis, 792 
of poliomyelitis, 772 
of scarlet fever, 626 
of tetanus, 758 
Serum treatment of influenza, 402 

of typhoid, 654 
Shingles (see also Herpes Zoster), 831 
Shock, anaphylactic, 518 
in intussusception, 288 
in typhoid, 655 
Shoe, proper, 20 
Shoulders, in lateral curvature of spine, 

857 
Sigmoid flexure, 73 

abnormalities of, 266, 267 
Simple catarrhal proctitis, 294 
Singultus, in pericarditis, 340 

in typhoid, 654 
Sinus thrombosis, 818 
Sitting, when established, 2 
Skin, cachectic, in syphilis, 676 
diseases of, 826 
blood in, 686 
in Addison's disease, 732 
in chlorosis, 696 
in cretinism, 719 
in eczema, 827 
in faulty metabolism, 298 
in foetal ichthyosis, 50 
in gastro-duodenitis, 228 
in meningitis, 787 
in Mongolian idiocy, 807 
in multiple neuritis, 752 
in pellagra, 255 

in pseudo-leukosmic anaemia, 695 
in secondary anaemia, 692 
in Winckel's disease, 40 
sensitive, 19 
Skull, in epilepsy, 760 
in hydrocephalus, 776 



Skull, in rachitis, 308, 310 

percussion of, 773 
Sleep, as diagnostic aid, 14 

examination during, 9 
Smallpox (see also Variola), 638 
Smegma, 363, 364 
Sneezing, in measles, 585 

in rubella, 578 
Sniffles (see Coryza). 

in syphilis, 675 
Snoring, a symptom of adenoids, 412 
of hypertrophied tonsils, 408 
of retro-pharyngeal abscess, 416 
Soap, use of, 19 
Sodium salts in milk, 142 
Somatose, 194 

Soor (see also Stomatitis Mycosa), 208 
Sore nipples, 92 
Soson, 195 
Spasm, clonic, 761 
epileptic, 760 
muscular, in rachitis, 312 
of bronchial muscles, 428 
of glottis, 428 
of larynx, 428 

in rachitis, 312 
of pylorus, 224 
Spasmodic cough, 422 
croup, 417 
laryngitis, 417 
treatment, 418 
Spasmophilia, 756 
in rachitis, 316 
Spasmus nutans, 743 
Spastic diplegia, 795 
Specific gravity of blood, at birth, 684 
of milk, 76, 77 
of urine, 877, 881 
Speech defects, 744 

late (see also Alalia idiopathica), 3, 

806 
sudden loss of, 4 
Spina bifida, 766, 846 
Spinal brace, 859 

cord, in acute myelitis, 764 
in chronic myelitis, 765 
in tubercular meningitis, 765 
malformations of, 766 
curvature, 855 

in rachitis, 319 
fluid, 673 

in meningitis, 786 
in pellagra, 255 
paralysis, 768 
Spine, abscess of, 851 
diseases of, 848 
in Pott's disease, 848 
in rachitis, 319 
lateral curvature of, 855 
paralysis of, 852 
Spirochaete pallida, 674 
Spleen, diseases of, 352 
enlargement of, 352 
in acute tuberculosis, 493 
in anaemia, 691 



942 



INDEX. 



Spleen, in chlorosis, 696 
in leukaemia, 693 

in malaria, 667 

in malignant endocarditis, 339 

in multiple neuritis, 752 

in pseudo-leukaemic anaemia, 695 

in rachitis, 307 

in typhoid, 650 

movable, 352 

palpation of, 352 

rupture of, 666 

wandering, 352 
Splenic anaemia, 691 
Sponge baths, to reduce temperature, 476 
Spontaneous haemorrhage, 39 
Spotted fever (see also Meningitis, Epi- 
demic), 784 
Spray, nasal, 393, 394 

throat, 392, 407 
Spray bath, cold, in hysteria, 751 
Sprue (see also Stomatitis Mycosa), 208 
Spurious, cephalhaematoma, 62 

hydrocephalus, 308, 310 
Sputum (see Expectoration). 

disinfection of, 894 

in bronchitis, 426 

in influenza, 396 

in tuberculosis, 495 

in typhoid, 656 

test for tubercle bacilli in, 888 
Square cranium in rachitis, 308, 312 
Squinting, 12 
Stammering, 744 
Staphylococci, in bronchitis, 425 

in broncho-pneumonia, 430 

in diphtheria, 504 

in empyema, 440 

in erysipelas, 658 

in follicular tonsillitis, 405 

in measles, 584 

in perinephritis, 584 

in pleurisy with effusion, 437 
Starch, 145 
Statistics (see Mortality). 

diphtheria, bacteria in, 548 
immunity from, 533 

measles with ear complications, 595 

mothers, percentage of, able to nurse, 
97 
unable to nurse, 100 
Status lymphaticus, 711 
Steak juice, 200 

Steam inhalations ( see Inhalations ) . 
Steapsin ferment -test, 225 
Stenosis, congenital, of larynx, 60 

hypertrophic, of the pylorus, 224 

laryngeal, following intubation and 
decubitus, 569 

in diphtheria, 512, 535, 542 

in retro-pharyngeal abscess, 416 

intubation in, 553 

pulmonary, 333 

recurring, 561 

spasmodic, 224 

subglottic, in syphilis, 554 



Stercoraceous vomiting (see also Faecal 

Vomiting), 281 
Sterilization of milk, 152 

causing constipation, 155 
chemical changes produced by, 128 
scurvy caused by, 303 
Sterno-mastoid, haematoma of, 61 
Sternum, 61 

in scoliosis, 857 
Stethoscopes, 328 
Stimulant, coffee as a, 202 
whisky as a, 203, 476 
Stock vaccines, 451 
Stomach, acids in, 6Q 
anatomy of, 65 
capacity of, 63, 69, 70 
diseases of, 65 
haemorrhage from, 731 
infantile, 65 
low position of, 232 
motor function of, 876 
mucous membrane of, 65 
physiology of, 65 
translumi nation of, 231 
ulcer of, 234 

unorganized ferments in, 66 
Stomach washing, 72 

in acute gastric catarrh, 207 
in chronic gastritis, 230 
technique of, 72 
Stomatitis, 205 
aphthosa, 206 
catarrhalis, 205 
croupous or diphtheritic, 209 
gangraenosa, 210 
mycosa, 208 
syphilitic, 210 
Stone in the bladder, 386 
Stools, infant, 237 

bloody, 242, 254, 286 

in Henoch's purpura, 708 
in intussusception, 286 
in syphilis, 675 
brown, 242 
casein in, 237, 240 
curds, white, in, 240 
diastatic enzymes in, 82 
disinfection of, 894 

in typhoid, 656 
dyspeptic, 243 
excess of fat in, 242 
green, 224, 239 

in derangement of liver, 347 
in faulty metabolism, 299 
in gastro-duodenitis, 254, 288 
in gastro-intestinal haemorrhage, 41 
in scarlet fever, 606 
in typhoid, 649 
in pyloric stenosis, 224 
mucus, 242 
normal, 237 

of buttermilk-fed infant, 177 
of nursling, 237 
scybalous, 243 
white or light gray, 242 



INDEX. 



943 



Strabismus, following cerebral paral- 
ysis, 797 
cerebro-spinal meningitis, 786 
pertussis, 457 
in tubercular meningitis, 780 
Streptococci, in acute peritonitis, 354 
in bronchitis, 425 
in broncho-pneumonia, 436 
in empyema, 440 
in erysipelas, 658 
in follicular tonsillitis, 405, 452 
in measles, 405 
in meningitis, 787 
in perinephritis, 374 
in pleurisy with effusion, 437 
in pseudo-diphtheria, 500 
smear from throat exudate, 506 
stain for, 889 
Strepto-diplococcus in scarlet fever, 600 
Streptolytic serum, in treatment of 
scarlet fever, 629 
in tubercular peritonitis, 358 
Strophulus infantum (see also Miliaria 

Rubra), 834 
Stupe, turpentine, 896 
Stuttering (see Speech Defects). 
Stye, 744, 825 
Subarachnoid space, fluid in, 736 

hsemorrhage into, 736 
Subcutaneous haemorrhage in scurvy, 303 
tendinous nodules, in rheumatism, 700 
Submaxillary glands, in diphtheria, 512, 
513 
in scarlet fever, 604, 613 
Subphrenic abscess, 351 
Substitute foods, 173 
Sucking, 65 
Sudamina, 834 

Sudden death, caused by careless injec- 
tion of antitoxin, 534 
caused by enlarged thymus, 711, 713 
in diphtheria, 528, 553 
in myocarditis, 344 
Suffocation from vomited milk, 28 

reflex, in angina Ludoviei, 216 
Sugars, 135 

excess of, causing colic, 273 
cane, 137 
in urine ( see Glycosuria ) . 

test for, 885 
malt, 136 
milk, 136 
Sulphur baths, 791 
Summer diarrhoea, 262 
Sunlight in treatment, of chlorosis, 697 
of peritonitis, 358 
of scurvy, 307 
of tuberculosis, 498 
Sunstroke, 246 
Superficial gangrene, 840 
Supplementary head, 62 
Suprarenal capsules, 370 
Sutures, separation of, in hydrocephalus, 

776 
Sweating, head, in rachitis, 222 



Sweating, in acute tuberculosis, 498 

in malarial fever, 670 

in very young infants, 12 
Symmetrical gangrene, 841 
Symptoms and diagnosis (see also Diag- 
nostic Suggestions), 9 
Syncope in pericarditis, 340 
Synovitis, complicating scarlet fever, 
614 

followed by knee-joint disease, 868 

purulent, 866 
Syphilis, 672 

butyric-acid test, 673 

congenital, 680 

diagnosis, 677 

haemorrhagic, 675 

hereditary ( see Inherited ) . 

inherited, 672 
Colles's law, 673 
contagion of, 673 

intubation in, 554 

luetin test, 678 

modes of infection, 672 

prognosis, 680 

spirochaste pallida, 674 
refringens, 674 

stomatitis in, 682 

symptoms, 674 
Syphilis, symptoms, bones, 674 
skin lesions, 676 
teeth, 676, 679 

transmission of, 680 

treatment, 680 

Wassermann reaction in, 678 
Syphilitic stomatitis, 210, 682 

teeth, 676, 679 
Syringe, nasal, 393 
Systolic murmurs, 330 

Tache cerebrale in tubercular menin- 
gitis, 786 
Tachycardia, 330 

in diphtheria, 527 

in exophthalmic goiter, 731 
Talipes, congenital, with rachitis, 320 
Tapeworms, 289 

Tapping the abdomen in ascites, 360 
Tea, 204 
Teeth, eruption of, 7 

grinding of, a symptom of worms, 290 

hygiene of, 17 

in adenoid vegetations, 411 

in cretinism, 719 

in rachitis, 312 

in stomatitis gangraenosa, 2.08 

in syphilis, 676, 679 
Teething (see Dentition). 
Temperature (see also Fever), 11 

effect of sugar feeding on, 137 

how to reduce, 474 

in distinguishing the still-born from 
the dead, 46 

variations in, 445 
Tender nipples, 92 
Tenesmus, in colicystitis, 386 



944 



INDEX. 



Tenesmus, in dysentery, 252 

in intussusception, 285 

in vesical calculi, 386 
Tertian, intermittent fever, 662 

double, 622 
Testicles, in hydrocele, 363 

in orchitis, complicating mumps, 717 

tuberculosis of, 486 

undescended, 365 
Tetanic seizures in rachitis, 312 
Tetanus, 758 

Tetany (see also Spasmophilia), 756 
Thermometer bath, 19 
Thirst, excessive, in diabetes insipidus, 
383 
in diabetes mellitus, 385 
in diarrhoea, 245 
in gastric catarrh, 219 
in gastro-duodenitis, 226 
Thoracoplasty in chronic empyema, 444 
Thorax, depression of, in rachitis, 312 

in empyema, 441 

sarcoma of, 842 
Threadworms, 292 
Throat, as diagnostic aid, 13 

diseases of, 291 

ice-bag, 427 

in diphtheria, 520 

in rubella, 578 

in scarlet fever, 604, 627 

spray, 407 
Thromboplastin in treatment of haemor- 
rhages, 42, 415 
Thrombosis, in diphtheria, 511, 524 

in gangrene, 839 

of pulmonary artery, 524 

sinus, 818 
Thrombokinase, deficiency of, causing 

haemorrhage, 40 
Thrush (see also Stomatitis Mycosa), 
208 

resembling diphtheria, 520 
Thymic asthma, 713 
Thymus, 711 

diseases of, 712 

primary tuberculosis of, 486 
Thyroid, abnormality of, 732 

desiccated extract of, in cretinism, 
730 

implantation of, 731 

in exophthalmic goiter, 731 

in leukaemia, 693 
Thyroiditis, acute, 732 
Tic, 745 
Tinea tonsurans, 837 

versicolor, 832 
Tongue, as diagnostic aid, 13 

bifid, 214 

epithelial desquamation of, 214 

hypertrophy of, 214 

in chorea, 746 

in cretinism, 719 

in diphtheria, 512 

in gastritis, 229 

in glossitis, 215 



Tongue, in measles, 585 
in rubella, 578 
in scarlet fever, 604 
tubercular infection of, 486 
Tongue-tie, 59 
Tonics, restorative, 625 

nutritive, 194 
Tonsillaris, angina, 403 
Tonsils, enlarged, 408 

causing bronchial asthma, 428 
indications for removal, 408 
predisposing to laryngeal stenosis, 
561 
in diphtheria, 512 
in leukaemia, 693 
tuberculosis of, 410 
Tonsillitis, 403 

bacteriology, 403 
sequelae, chorea, 746 

rheumatism, 699 
significance of, 404 
treatment, 404 
serum, 452 
croupous, 405 
follicular, 404, 522 
hypertrophic, chronic, 407 
phlegmonous, 406 
ulcerative, 522 
ulcero-membranous, 405 
neosalvarsan in, 406 
Tonsillotome, Baginsky, 409 

Mackenzie, 409 
Tonsillotomy, 409 

bleeding following, 408, 409 
Torticollis, 704 

treatment, 705 
Toxaemia, in auto-intoxication, 285 

in dysentery, 253 
Toxicosis, 299 

Toxin, diphtheria, effect of, on nervous 
system of animals, 510 
in scarlet fever, 604, 606 
Toxins (see Poisons), 
causing convulsions, 739 
elimination of, 538 
Trachea, cannula, silver, 575 
hard-rubber, 575 
stenosis of, 546 
Tracheotomy, in laryngeal stenosis, 574 
operation, 575 

after-treatment, 575 
in syphilitic subglottic stenosis, 668 
Trachoma, 807 
Transfusion, 629 

in haemorrhage of new-born, 42 
Transamination of stomach, 231, 232 
Traumatism, causing arthritis, 866 
aphthae, 17 
cerebral abscess, 804 
epilepsy, 760 
joint disease, 864 
Tropon, 195 

Trousseau's sign in tetany, 750 
Truss, in umbilical hernia, 289 
Trypsin ferment test, 226 



INDEX. 



9-15 



Tubercle bacilli, disseminated by cows, 
124 
in tubercular perinephritis, 375 
in the urine, 880 
stain for, in sputum, 888 
transmission of, 487 
Tubercular, adenitis, 714 
empyema, 444 
hip-joint disease, 861 
meningitis, 779 
peritonitis, 357 
Tuberculides, 496 
Tuberculin, injections, 499 
test for diagnosis, 300, 496 
cutaneous reaction, 496 
ophthalmo reaction, 497 
Tuberculosis, . following cerebral pneu- 
monia, 472 
chlorosis, 696 
empyema, 444 
scrofulosis, 484 
in the new-born, 55, 484 
manifestations in bladder, 387 

on skin, 496 
modes of infection, 131, 485 
of hip-joint, 861 
of pericardium, 342 . 
of tonsils, 410 
predisposing causes, 486 
acute, 483 

bacteriology, 486 
D'Espine's sign in, 494 
diagnosis, 496 

from faulty metabolism, 300 
from syphilis, 678 
Tuberculosis, acute, diagnosis, from 
typhoid, 495 
sputum, 495 

method of obtaining, 495 
tuberculin reaction, 496 
etiology, 483 

pathological anatomy, 489 
prognosis, 496 
symptoms, 493 
nigbt sweats, 498 
physical signs, 493 
in nurslings, 494 
resembling intermittent fever, 493 
temperature, 493 
treatment, 497 

heliotherapy in, 498 
bovine, 483 

chronic pulmonary, 479 
pathology, 479 
symptoms, 481 
treatment, 497 
miliary (see Acute). 
Tuberculous adenitis, 714 
ankle-joint, 865 
broncho-pneumonia, 479 
coxitis, 862 
elbow-joint, 865 
hip-joint, 861 

infection, through milk, 122, 131, 483 
knee-joint, 864 



Tuberculous nodules, 780 
pneumonia, 477 
wrist-joint, 865 
Tumor of bladder, 387 
of kidney, 379 
sacral, 62 

spindle-cell sarcoma, 842 
spongy (see also Angeioma), 57 
Tunica vaginalis, hydrocele of, 363 
Turbinates, hypertrophied, causing bron- 
chial asthma, 428 
Turpentine stupes, 896 
Twitching, in chorea, 746 

in meningitis, 782 
Tympanites (see also Intestinal Colic), 
273 
a symptom of worms, 291 
complicating typhoid, 654 
in intussusception, 287 
Typhoid fever, 646 
bacteriology, 646 
complications, 654 
course, 654 
diagnosis, 650 
eruption, 651 
etiology, 646 
foetal and infantile, 647 
internal haemorrhage, 653 
intestinal perforation, 653 
leucopaenia in, 652 
pathology, 646 
prognosis, 646 
symptoms, 648 
temperature, 649 
treatment, 654 
vaccine, 542 

Uffelmann's test for lactic acid in stom- 
ach contents, 875 
Ulcer, in scrofula, 681 
in syphilis, 681 
of stomach, 234, 696 
of tonsil, 405 
Ulcerations, aphthous, 206 

due to intubation tube, 543 
Ulcerative proctitis, 295 

tonsillitis, 522 
Ulcero-membranous tonsillitis, 405 

resembling diphtheria, 520 
Umbilical cord, 17 

haemorrhage from, 42 

in syphilis, 675 
hernia, 288 
polypus, 36 
Umbilicus, bleeding from, 35, 39 

in Meckel's diverticulum, 36 
Uncinariasis, 293 
Undescended testicle, 365 
Unna's soft zinc paste, 828 
Uraemia in post-scarlatinal nephritis, 617 
Urea in diabetes insipidus, 383 
Urethra in vaginitis, 368 
Urethral calculi, 3S6 
Urethritis, 366 
Uric acid, in blood, 708 



60 



946 



INDEX. 



Urio acid, in urine, 880 
of new-born, 878 
Uricaeidaemia (see also Lithaemia), 705 
Urine, 877 

albumin in, 878 

ammoniacal, 132 
test for, 881 

bloody, 382 

diazo-reaction in, 883 
in typhoid, 651, 653 

disinfection of, 656, 894 

fermentation test, 887 

first, 877 

in atrophy, 875 

in auto-intoxication, 283 

in colicystitis, 385 

in cystitis, 387 

In derangement of liver, 348 

in diabetes insipidus, 383 

in diabetes mellitus, 385 

in diphtheria, 228, 515, 879 

in epilepsy, 764 

in gastro-duodenitis, 228 

in icterus neonatorum, 878 

in leukaemia, 880 

in lithaemia, 708 

in measles, 588 

in nephritis, 372 

in pneumonia, 467 

in pyelitis, 377 

in scarlet fever, 604, 606 

in septic diphtheria, 523, 526 

in typhoid, 651, 653, 656 

in tuberculosis, 493 

in Winckel's disease, 41 

incontinence of, in multiple neuritis, 
752 
in ectopia vesicae, 378 

indican, test for, 884 

method of collecting, 877 

of breast-fed babies, 877 

of new-born babies, 878 

sodium chloride in, 878 

specific gravity, 886 

sugar in, 383 
test for, 885 

test for blood in, 885 

test for diacetic acid, 886 

test for pus, 886 

urobilinogen reaction in, 238 
Urino-pyknometer, 880 
Urticaria, 830 
Useless coughs, 422 
Uvula, bifid. 215 

enlarged, causing bronchial asthma, 
428 

inflamed, in spasmodic laryngitis, 417 

in scarlet fever, 604 

Vaccination, 644 
Vaccines, bacterial, 450 

autogenous, 451 

stock, 451 

in erysipelas, 452, 660 

in furunculosis, 451, 835 



Vaccines, in influenza, 402 

in pertussis, 452 

in pneumonia, 454 

in rabies, 451 

in sinus thrombosis, 818 

in streptococcus infections, 452 

in tonsillitis, 452 

in typhoid, 452 

in vulvo-vaginitis, 451 
Vaccinia, 645 

Vagina, rectum terminating in, 64 
Vaginitis, 366 

catarrhal, 366 

following scarlet fever, 617 

gonorrhceal, 366 
Varicella, 633 

complicating erysipelas, 635 

diagnosis, 633 

from impetigo, 635 
from variola, 634 

pathology, 633 

treatment, 636 
Variola, 638 

complications, 642 

desquamation, 640 

diagnosis, differential, 641 

eruption, 639 

etiology, 638 

isolation, 642 

mode of infection, 639 

mortality, 638 

prognosis and course, 642 

symptoms, 639 

treatment, 642 
Varioloid, 641 
Vascular nsevus, 836 

Vasomotor disturbance causing asth- 
matic attacks, 428 
Vegetable milk, Lahmann's, 178 
Vein, transverse nasal, in adenoids, 412 

umbilical, 325 
Veins, engorgement of, in insolation, 246 

of abdomen, in ascites, 358 

of scalp, in hydrocephalus, 775 
in rachitis, 312 

splenic, in malarial fever, 667 

varicose, in chlorosis, 696 
Velum palatinum, in diphtheria, 512 
Venesection, 897 
Venous murmurs, 332 
Vermiform appendix, location of, 73 
Vernix caseosa, 18 
Verruca, 838 

Vertebrae, in scoliosis, 857 
Vertigo, a symptom of worms, 290 
Vesical calculi, 386 
Vicarious menstruation, 368 
Vincent's bacillus, 406 
Vitamines, 144 
Vocal resonance, 424 
Voice, husky, in papillomata, 846 

in pleurisy with effusion, 438 

in syphilis, 680 

nasal, in diphtheria, 511, 526 

with hypertrophy of tonsils, 408 



INDEX. 



947 



Vomiting, 61 

chronic, 22S 

cyclic, 235 

faecal, in intussusception, 281, 286 

in dilatation of stomach, 231 

in diphtheria, 514 

in gastro-intestinal haemorrhage, 41 

in Henoch's purpura, 708 

in influenza, 398 

in measles, 585 

in meningitis, 782, 786 

in pachymeningitis, 794 

in pertussis, 456 

in premature infants, 33 

in pyloric obstruction, 224 

in rubella, 578 

in scarlet fever, 600, 604 

in typhoid, 649 

significance of, 71 
Vulvo- vaginitis, 366 

following scarlet fever, 622 
serum treatment, 451 

Walking, first attempts at, 2 

in congenital dislocation of hip, 863 

in hereditary ataxy, 767 
Wampole's milk food, 186 
Wandering pneumonia, 464 

spleen, 352 
Warts (see also Verruca), 838 

syphilitic, 682 
Wassermann reaction in syphilis, 678 
Wasting disease, 321 
Water-ices, 201 
Water on the brain (see also Chronic 

Hydrocephalus), 776 
Waxy liver, 349 
Weaning, 107 
Weighing to determine the quantity of 

milk an infant has taken, 109 
Weight, at birth, 109 

disturbance, 168 

effect of sugar feeding on, 136, 137 

gain in, of an infant fed on Eskay's 
food, 111 



Weight, gain in, of an infant fed on 
modified milk, 112 

on mother's milk, 109 
on Walker-Gordon modified 
milk, 112 
of a prematurely born infant, 33 
of a wet-nursed infant, 111 
loss of, 299 

during first week, 80 
Weight-scales, Chatillon, 108 
Werlhof's disease (see also Purpura 

Haemorrhagica ) , 706 
Wet-nurse, 97 

dangers of syphilis, 210 
diet of a, 103 
how to examine, 97, 99 
selection of, 97, 100 
tricks of a, 98 
with goiter, 98 
Wet-nursing, in New York, 106 

in Prague, 105 
Wheal in urticaria, 830 
Whey, 873 
Whooping-cough (see also Pertussis), 

455 
Widal's reaction in typhoid fever, 650 
Winckel's disease, 40 
Woman's milk (see Milk). 
Worms, causing convulsions, 739, 741 
pinworms, 292 
roundworms, 290 
tapeworm, 289 
threadworm, 292 
Wrist-joint disease, 865 

in rachitis, 314, 315 
Wry-neck (see also Torticollis), 704 

Xanthin, 708 

X-ray examination, as diagnostic aid, 
15 

Yawning, in malarial fever, 671 
Zoolak, 189 



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